Basic Information
| Provider Information | |||||||||
| NPI: | 1245862689 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SERC REHABILITATION PARTNERS LLC | ||||||||
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| OtherOrganizationName: | SERC - FAYETTEVILLE EAST, AR | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6397 LEE HWY STE 300 | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374214915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232387217 | ||||||||
| FaxNumber: | 4232383473 | ||||||||
| Practice Location | |||||||||
| Address1: | 2607 E MISSION BLVD STE 3 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727033260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794359227 | ||||||||
| FaxNumber: | 4794359353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2020 | ||||||||
| LastUpdateDate: | 03/18/2020 | ||||||||
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| AuthorizedOfficialLastName: | JOHANNESON | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP REVENUE CYCLE OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 4232382313 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.