Healthcare Provider Details

I. General information

NPI: 1346473873
Provider Name (Legal Business Name): GENESIS REHAB.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2009
Last Update Date: 09/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12858 STRATHEARN DRIVE
ST. LOUIS MO
63146
US

IV. Provider business mailing address

12858 STRATHEARN DR
SAINT LOUIS MO
63146-3773
US

V. Phone/Fax

Practice location:
  • Phone: 314-469-5008
  • Fax:
Mailing address:
  • Phone: 314-469-5008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number100097
License Number StateMO

VIII. Authorized Official

Name: LYRA R PHAN
Title or Position: PHYSICAT THERAPIST
Credential: PHYSICAL THERAPY
Phone: 314-469-5008