Provider Demographics
NPI:1427007566
Name:SERC OF LIBERTY LLC
Entity type:Organization
Organization Name:SERC OF LIBERTY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:E
Authorized Official - Last Name:HELMER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:816-792-0775
Mailing Address - Street 1:1512 NE 96TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-1348
Mailing Address - Country:US
Mailing Address - Phone:816-792-0775
Mailing Address - Fax:816-792-0776
Practice Address - Street 1:1512 NE 96TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-1348
Practice Address - Country:US
Practice Address - Phone:816-792-0775
Practice Address - Fax:816-792-0776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO112594225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO31732022OtherBCBS
MOP750000Medicare PIN