Healthcare Provider Details

I. General information

NPI: 1083030100
Provider Name (Legal Business Name): GENESIS REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2014
Last Update Date: 03/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 SAINT JOHN RD
ELIZABETHTOWN KY
42701-2918
US

IV. Provider business mailing address

584 CLOVER LN UNIT A
ELIZABETHTOWN KY
42701-2992
US

V. Phone/Fax

Practice location:
  • Phone: 270-769-3314
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number4023
License Number StateKY

VIII. Authorized Official

Name: CRYSTAL CLAYTON
Title or Position: SPEECH-LANGUAGE PATHOLOGIST
Credential:
Phone: 270-256-8293