Healthcare Provider Details

I. General information

NPI: 1467575183
Provider Name (Legal Business Name): GENESIS REHABILITATION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 PEABODY ST
TILTON NH
03276-5407
US

IV. Provider business mailing address

4 PEABODY ST
TILTON NH
03276-5407
US

V. Phone/Fax

Practice location:
  • Phone: 603-524-3340
  • Fax:
Mailing address:
  • Phone: 603-286-9493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0519
License Number StateNH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DWAYNE OOTHOUDT
Title or Position: OCCUPATIONAL THERAPY ASSISTANT
Credential:
Phone: 603-524-3340