Basic Information
| Provider Information | |||||||||
| NPI: | 1063681831 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GENESIS HEALTH DEVELOPMENT, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BROOKS REHAB CENTER/CLUBHOUSE | ||||||||
| 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: | 2700 UNIVERSITY BLVD W | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322172147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046746400 | ||||||||
| FaxNumber: | 9043457284 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2008 | ||||||||
| LastUpdateDate: | 08/22/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BAER | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9043457473 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GENESIS HEALTH DEVELOPMENT, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| 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 | 693643179 | 01 | FL | MEDICAID | OTHER |