Provider Demographics
NPI:1295054518
Name:SERC OF CLINTON INC
Entity type:Organization
Organization Name:SERC OF CLINTON INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCWILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:816-524-5287
Mailing Address - Street 1:109 W FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-2007
Mailing Address - Country:US
Mailing Address - Phone:816-524-5287
Mailing Address - Fax:816-434-6632
Practice Address - Street 1:109 W FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MO
Practice Address - Zip Code:64735-2007
Practice Address - Country:US
Practice Address - Phone:816-524-5287
Practice Address - Fax:816-434-6632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-26
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO003718225XH1200X
MO105255225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO44281011OtherBCBS KC
MO44281011OtherBCBS KC