Healthcare Provider Details

I. General information

NPI: 1386911600
Provider Name (Legal Business Name): GENESIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2011
Last Update Date: 12/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 S INDIANA AVE
CHICAGO IL
60616-3841
US

IV. Provider business mailing address

1512 W SCHOOL ST APT 2
CHICAGO IL
60657-9536
US

V. Phone/Fax

Practice location:
  • Phone: 312-842-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number146010384
License Number StateIL

VIII. Authorized Official

Name: ANNA DOROTHEA MUELLER
Title or Position: SPEECH-LANGUAGE PATHOLOGIST
Credential:
Phone: 616-520-3959