Healthcare Provider Details

I. General information

NPI: 1164876074
Provider Name (Legal Business Name): GENESIS HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2016
Last Update Date: 04/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 PALOMAS AVE NE
ALBUQUERQUE NM
87109-5264
US

IV. Provider business mailing address

8100 PALOMAS AVE NE
ALBUQUERQUE NM
87109-5264
US

V. Phone/Fax

Practice location:
  • Phone: 505-821-4200
  • Fax: 505-822-0234
Mailing address:
  • Phone: 505-821-4200
  • Fax: 505-822-0234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number2504
License Number StateNM

VIII. Authorized Official

Name: MR. MICHAEL GLADE
Title or Position: THERAPY MANAGER
Credential:
Phone: 505-821-4200