Healthcare Provider Details

I. General information

NPI: 1982918843
Provider Name (Legal Business Name): GENESIS HEALTHCARE LEBANON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2010
Last Update Date: 08/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1218 SOUTH RANDOLPH ROAD
RANDOLPH CENTER VT
05061
US

IV. Provider business mailing address

1218 S RANDOLPH RD
RANDOLPH CENTER VT
05061-9528
US

V. Phone/Fax

Practice location:
  • Phone: 802-728-9786
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: TAMMY REA-FARMER
Title or Position: PT
Credential:
Phone: 802-295-7391