Basic Information
| Provider Information | |||||||||
| NPI: | 1043524515 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GENECCO REHAB INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17380 ALT A1A | ||||||||
| Address2: | SUITE 305 | ||||||||
| City: | JUPITER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334775860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617411661 | ||||||||
| FaxNumber: | 5617411663 | ||||||||
| Practice Location | |||||||||
| Address1: | 6451 N FEDERAL HWY | ||||||||
| Address2: | SUITE 127 | ||||||||
| City: | FT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333081402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9546896797 | ||||||||
| FaxNumber: | 9546896264 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2010 | ||||||||
| LastUpdateDate: | 07/27/2010 | ||||||||
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| AuthorizedOfficialLastName: | GENECCO | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5617411661 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.