Basic Information
| Provider Information | |||||||||
| NPI: | 1053659490 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GENESIS HEALTH CARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11548 DAWSON ROAD | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706252944 | ||||||||
| FaxNumber: | 2704439407 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420010749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705385440 | ||||||||
| FaxNumber: | 2704439407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2013 | ||||||||
| LastUpdateDate: | 01/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | MCKINNEY | ||||||||
| AuthorizedOfficialFirstName: | TONIA | ||||||||
| AuthorizedOfficialMiddleName: | MICHELLE | ||||||||
| AuthorizedOfficialTitleorPosition: | COTA/L | ||||||||
| AuthorizedOfficialTelephone: | 2706252944 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | THERAPIST ASSISTANT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | A2305 | KY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.