Healthcare Provider Details

I. General information

NPI: 1952333114
Provider Name (Legal Business Name): GENESIS REHABILITATION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7802 NORTH 43RD AVENUE SUITE 3
GLENDALE AZ
85301
US

IV. Provider business mailing address

P O BOX 39717
GLENDALE AZ
85069
US

V. Phone/Fax

Practice location:
  • Phone: 623-939-3112
  • Fax:
Mailing address:
  • Phone: 623-939-3112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number3951
License Number StateAZ

VIII. Authorized Official

Name: MR. ADEBOLA BOB ADEKANMBI
Title or Position: DIRECTOR
Credential: PT
Phone: 623-939-3112