Healthcare Provider Details

I. General information

NPI: 1215355243
Provider Name (Legal Business Name): SERC REHABILITATION PARTNERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2014
Last Update Date: 04/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3727 GENE FIELD RD
SAINT JOSEPH MO
64506-1806
US

IV. Provider business mailing address

17134 BEL RAY PL
BELTON MO
64012-5331
US

V. Phone/Fax

Practice location:
  • Phone: 816-396-8635
  • Fax: 816-364-3522
Mailing address:
  • Phone: 816-226-4011
  • Fax: 816-524-6115

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: KILEY RUSSELL
Title or Position: MGR OF PROVIDER/PAYER ENROLLMENT
Credential:
Phone: 423-238-8923