Basic Information
| Provider Information | |||||||||
| NPI: | 1033154992 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GENESIS HEALTH DEVELOPMENT INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | BROOKS REHAB CENTER/PALM COAST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3599 UNIVERSITY BLVD S | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322164252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043457291 | ||||||||
| FaxNumber: | 9043457284 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 COMMED BLVD | ||||||||
| Address2: | |||||||||
| City: | ORANGE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327638321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867777488 | ||||||||
| FaxNumber: | 9043457284 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 08/22/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BAER | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9043457473 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GENESIS HEALTH DEVELOPMENT INC | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 8869570-05 | 05 | FL | MEDICAID |