Provider Demographics
NPI:1982018412
Name:SERC REHABILITATION PARTNERS LLC
Entity Type:Organization
Organization Name:SERC REHABILITATION PARTNERS LLC
Other - Org Name:SERC - RAYTOWN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MGR OF PROVIDER AND PAYER ENROLLMEN
Authorized Official - Prefix:
Authorized Official - First Name:KILEY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-238-8923
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:816-226-4011
Mailing Address - Fax:816-524-6115
Practice Address - Street 1:4277 STERLING AVE
Practice Address - Street 2:
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64133-1351
Practice Address - Country:US
Practice Address - Phone:816-353-0060
Practice Address - Fax:816-358-5830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-12
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA4370OtherMEDICARE PTAN