1952359390 NPI number — SERC OF JOHNSON COUNTY LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952359390 NPI number — SERC OF JOHNSON COUNTY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SERC OF JOHNSON COUNTY LLC
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:
6
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:
1952359390
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
801 N MUR LEN RD
Provider Second Line Business Mailing Address:
SUITE 111
Provider Business Mailing Address City Name:
OLATHE
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66062-1794
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-782-7734
Provider Business Mailing Address Fax Number:
913-782-7209

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 N MUR LEN RD
Provider Second Line Business Practice Location Address:
SUITE 111
Provider Business Practice Location Address City Name:
OLATHE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66062-1794
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-782-7734
Provider Business Practice Location Address Fax Number:
913-782-7209
Provider Enumeration Date:
05/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STONE
Authorized Official First Name:
ROBYN
Authorized Official Middle Name:
S
Authorized Official Title or Position:
CLINIC DIRECTOR
Authorized Official Telephone Number:
913-782-7734

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  11-02758 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 34414021 . This is a "BCBS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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