Healthcare Provider Details

I. General information

NPI: 1457734717
Provider Name (Legal Business Name): SERC REHABILITATION PARTNERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2015
Last Update Date: 07/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 W MAPLE AVE
INDEPENDENCE MO
64050-2814
US

IV. Provider business mailing address

8823 PRODUCTION LN
OOLTEWAH TN
37363-6511
US

V. Phone/Fax

Practice location:
  • Phone: 816-254-4548
  • Fax: 816-254-4605
Mailing address:
  • Phone: 423-238-7217
  • Fax: 423-238-3473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KEVIN JOHANNESON
Title or Position: VP REVENUE CYCLE OPERATIONS
Credential:
Phone: 423-238-7217