Healthcare Provider Details

I. General information

NPI: 1386997781
Provider Name (Legal Business Name): GENESIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2012
Last Update Date: 10/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1513 S DIXIELAND RD
ROGERS AR
72758-4935
US

IV. Provider business mailing address

4106 CANDLEWOOD PL
ROGERS AR
72758-8253
US

V. Phone/Fax

Practice location:
  • Phone: 479-636-5841
  • Fax:
Mailing address:
  • Phone: 479-263-1268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberOTR1586
License Number StateAR

VIII. Authorized Official

Name: MR. MICHAEL DAVID
Title or Position: PHYSICAL THERAPY ASSISTANT
Credential: PTA
Phone: 479-330-0187