Provider Demographics
NPI:1306053632
Name:SERC OF LEE'S SUMMIT
Entity type:Organization
Organization Name:SERC OF LEE'S SUMMIT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, MANAGER, PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:WERNSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:816-537-5650
Mailing Address - Street 1:3500 SW MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64082-2327
Mailing Address - Country:US
Mailing Address - Phone:816-537-5650
Mailing Address - Fax:816-537-5649
Practice Address - Street 1:3500 SW MARKET ST
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64082-2327
Practice Address - Country:US
Practice Address - Phone:816-537-5650
Practice Address - Fax:816-537-5649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
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
MOT070000Medicare ID - Type UnspecifiedLEE'S SUMMIT MEDICARE