Healthcare Provider Details

I. General information

NPI: 1932571528
Provider Name (Legal Business Name): GENESIS REHAB SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2015
Last Update Date: 10/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 E NIZHONI BLVD
GALLUP NM
87301-5794
US

IV. Provider business mailing address

306 E. NIZHONI BLVD.
GALLUP NM
87301
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-9551
  • Fax:
Mailing address:
  • Phone: 505-863-9551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberA-0411
License Number StateNM

VIII. Authorized Official

Name: MRS. GRETA RUCKER
Title or Position: PTA/DOR
Credential:
Phone: 505-863-9551