=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346473873
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENESIS REHAB.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2009
-----------------------------------------------------
Last Update Date | 09/01/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12858 STRATHEARN DRIVE
-----------------------------------------------------
City | ST. LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-469-5008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12858 STRATHEARN DR
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63146-3773
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-469-5008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAT THERAPIST
-----------------------------------------------------
Name | LYRA R PHAN
-----------------------------------------------------
Credential | PHYSICAL THERAPY
-----------------------------------------------------
Telephone | 314-469-5008
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 100097
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------