Basic Information
| Provider Information | |||||||||
| NPI: | 1679817696 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GENESIS REHAB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 905 CHARLESTON GRN | ||||||||
| Address2: | |||||||||
| City: | MALVERN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193552457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4845576601 | ||||||||
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| Practice Location | |||||||||
| Address1: | 146 MARPLE RD | ||||||||
| Address2: | |||||||||
| City: | BROOMALL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190082040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103560100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2012 | ||||||||
| LastUpdateDate: | 11/15/2012 | ||||||||
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| AuthorizedOfficialLastName: | CARBO | ||||||||
| AuthorizedOfficialFirstName: | MARIE | ||||||||
| AuthorizedOfficialMiddleName: | ANTOINETTE | ||||||||
| AuthorizedOfficialTitleorPosition: | OCCUPATIONAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 4845576601 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.S. OTR/L | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | OC012201 | PA | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
No ID Information.