Healthcare Provider Details

I. General information

NPI: 1023526209
Provider Name (Legal Business Name): GENESIS REHABILITATION CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2018
Last Update Date: 10/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3440 WILSHIRE BLVD STE 909
LOS ANGELES CA
90010-2101
US

IV. Provider business mailing address

3440 WILSHIRE BLVD STE 909
LOS ANGELES CA
90010-2101
US

V. Phone/Fax

Practice location:
  • Phone: 213-739-9982
  • Fax: 213-739-9983
Mailing address:
  • Phone: 213-739-9982
  • Fax: 213-739-9983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number190039AP
License Number StateCA

VIII. Authorized Official

Name: MR. GEORGE MORENO
Title or Position: PROGRAM DIRECTOR
Credential: CADC II, CCDS
Phone: 213-739-9982