MEDICARE: SERC REHABILITATION PARTNERS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1689079899
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SERC REHABILITATION PARTNERS LLC

Provider Business Mailing Address
First Line	:	8823 PRODUCTION LN
Second Line	:
City	:	OOLTEWAH
State	:	TN
Zip	:	37363-6511
Country	:	US
Telephone Number	:	423-238-7217
Fax Number	:	423-238-3473

Provider Business Practice Location Address
First Line	:	2603 W PLEASANT GROVE RD
Second Line	:	STE 104
City	:	ROGERS
State	:	AR
Zip	:	72758-8514
Country	:	US
Telephone Number	:	816-226-4011
Fax Number	:	816-524-6115

Authorized Official
Title or Position	:	VP REVENUE CYCLE OPERATIONS
Name	:	KEVIN JOHANNESON
Credential	:
Telephone Number	:	423-238-7217

Provider Enumeration Date	:	10/30/2014
Last Update Date	:	10/30/2014

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