Provider Demographics
NPI:1336198522
Name:SERC OF KEARNEY INC
Entity Type:Organization
Organization Name:SERC OF KEARNEY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:816-903-0775
Mailing Address - Street 1:101 W 92 HWY
Mailing Address - Street 2:SUITE H
Mailing Address - City:KEARNEY
Mailing Address - State:MO
Mailing Address - Zip Code:64060-7590
Mailing Address - Country:US
Mailing Address - Phone:816-903-0775
Mailing Address - Fax:816-903-0776
Practice Address - Street 1:101 W 92 HWY
Practice Address - Street 2:SUITE H
Practice Address - City:KEARNEY
Practice Address - State:MO
Practice Address - Zip Code:64060-7590
Practice Address - Country:US
Practice Address - Phone:816-903-0775
Practice Address - Fax:816-903-0776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002030223225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO37002019OtherBCBS
MO37002019OtherBCBS