Healthcare Provider Details

I. General information

NPI: 1487999397
Provider Name (Legal Business Name): GENESIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2012
Last Update Date: 12/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15625 WOODLAND POINT RD
NEWBURG MD
20664-6304
US

IV. Provider business mailing address

15625 WOODLAND POINT RD
NEWBURG MD
20664-6304
US

V. Phone/Fax

Practice location:
  • Phone: 240-210-4075
  • Fax:
Mailing address:
  • Phone: 240-210-4075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberA3594
License Number StateMD

VIII. Authorized Official

Name: MISS AMANDA MARTIN
Title or Position: PTA
Credential:
Phone: 240-210-4075