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General NPI Number Information
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NPI Number | 1427007566
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Entity Type | Organization
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Legal Business Name | SERC OF LIBERTY LLC
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Dates
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Enumeration Date | 05/08/2006
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Last Update Date | 11/02/2012
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Provider Practice Location Address
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Address Line | 1512 NE 96TH ST SUITE A
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City | LIBERTY
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State | MO
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Zip | 64068-1348
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Country | US
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Telephone | 816-792-0775
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Fax | 816-792-0776
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Provider Business Mailing Address
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Address Line | 1512 NE 96TH ST SUITE A
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City | LIBERTY
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State | MO
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Zip | 64068-1348
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Country | US
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Telephone | 816-792-0775
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Fax | 816-792-0776
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Authorized Official
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Title or Position | CLINIC DIRECTOR
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Name | CHAD E HELMER
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Credential | PT
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Telephone | 816-792-0775
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 112594
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License Number State | MO
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