Basic Information
| Provider Information | |||||||||
| NPI: | 1013311257 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SERC REHABILITATION PARTNERS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SERC - GRAIN VALLEY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8823 PRODUCTION LN | ||||||||
| Address2: | |||||||||
| City: | OOLTEWAH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373636511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232387217 | ||||||||
| FaxNumber: | 4232383473 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 SW EAGLES PKWY | ||||||||
| Address2: | |||||||||
| City: | GRAIN VALLEY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640298512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164432375 | ||||||||
| FaxNumber: | 8164432380 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2014 | ||||||||
| LastUpdateDate: | 10/17/2014 | ||||||||
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| AuthorizedOfficialLastName: | JOHANNESON | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP REVENUE CYCLE OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 4232387217 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | MA4370 | 01 | MO | MEDICARE PTAN | OTHER |