Basic Information
| Provider Information | |||||||||
| NPI: | 1790062594 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GENESIS REHAB SERVICES LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GENESIS REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9430 WICKER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT JOHN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463739768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2196165727 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9430 WICKER AVE | ||||||||
| Address2: | 1534 119TH STREET | ||||||||
| City: | SAINT JOHN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463739768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2196555285 | ||||||||
| FaxNumber: | 2196555472 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2011 | ||||||||
| LastUpdateDate: | 05/04/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MALIK | ||||||||
| AuthorizedOfficialFirstName: | CHARRU | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SOLE MBR | ||||||||
| AuthorizedOfficialTelephone: | 2196165727 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | M.H.S, P.T. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.