=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396989323
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENESIS REHAB SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2009
-----------------------------------------------------
Last Update Date | 04/21/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 809 ADDISON CT
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23462-6904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-463-0670
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 809 ADDISON CT
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23462-6904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-463-0670
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OTR/L
-----------------------------------------------------
Name | MRS. CHARISE LILLIAN WILSON-HAMMOND
-----------------------------------------------------
Credential | OTR/L
-----------------------------------------------------
Telephone | 757-463-0670
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 0119004820
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------