1205030699 NPI number — SERC HAND OF CASS COUNTY L.L.C.

Table of content: (NPI 1205030699)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205030699 NPI number — SERC HAND OF CASS COUNTY L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SERC HAND OF CASS COUNTY L.L.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205030699
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17134 BEL RAY PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELTON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64012-5331
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-318-0436
Provider Business Mailing Address Fax Number:
816-318-0437

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17134 BEL RAY PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELTON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64012-5331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-318-0436
Provider Business Practice Location Address Fax Number:
816-318-0437
Provider Enumeration Date:
06/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HARNDEN
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
OWNER, MANAGER, THERAPIST
Authorized Official Telephone Number:
816-318-0436

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X , with the licence number:  2006025819 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 38514011 . This is a "BKCS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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