Provider Demographics
NPI:1063628352
Name:SPINE & EXTREMITY REHABILITATION CENTER OF RAYTOWN, INC.
Entity type:Organization
Organization Name:SPINE & EXTREMITY REHABILITATION CENTER OF RAYTOWN, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER-MANAGER-PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:E
Authorized Official - Last Name:NAUMANN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:816-737-5500
Mailing Address - Street 1:10801 E STATE ROUTE 350
Mailing Address - Street 2:
Mailing Address - City:RAYTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:64138-2367
Mailing Address - Country:US
Mailing Address - Phone:816-737-5500
Mailing Address - Fax:816-737-5504
Practice Address - Street 1:10801 E STATE ROUTE 350
Practice Address - Street 2:
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64138-2367
Practice Address - Country:US
Practice Address - Phone:816-737-5500
Practice Address - Fax:816-737-5504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOK860000Medicare ID - Type UnspecifiedBELTON MEDICARE
MOK860000BMedicare ID - Type UnspecifiedRAYTOWN MEDICARE