=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073834420
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENESIS REHAB SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2010
-----------------------------------------------------
Last Update Date | 06/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 LITTON LN
-----------------------------------------------------
City | BLACKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24060-6399
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-443-3436
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 NEW RIVER DR APT. B
-----------------------------------------------------
City | RADFORD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24141-1889
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH LANGUAGE PATHOLOGY CF
-----------------------------------------------------
Name | MS. DIANE MARIE BARBERNITZ
-----------------------------------------------------
Credential | M.S.
-----------------------------------------------------
Telephone | 301-642-7659
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 2202006040
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------