Healthcare Provider Details

I. General information

NPI: 1518194513
Provider Name (Legal Business Name): SERC HAND NORTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2009
Last Update Date: 06/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1512 NE 96TH ST
LIBERTY MO
64068-7174
US

IV. Provider business mailing address

1512 NE 96TH ST
LIBERTY MO
64068-7174
US

V. Phone/Fax

Practice location:
  • Phone: 816-792-0775
  • Fax: 816-792-0776
Mailing address:
  • Phone: 816-792-0775
  • Fax: 816-792-0776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number004600
License Number StateMO

VIII. Authorized Official

Name: KRISTEN R LARSON
Title or Position: CLINIC MANAGER
Credential: OTR/L, CHT
Phone: 816-792-0775