=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801028956
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENESIS REHAB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2009
-----------------------------------------------------
Last Update Date | 08/21/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 S NEW FLORISSANT RD
-----------------------------------------------------
City | FLORISSANT
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63031-6716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-830-7950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 647 LOGAN VALLEY DR
-----------------------------------------------------
City | SAINT PETERS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63376-3799
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-379-9106
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM MANAGER
-----------------------------------------------------
Name | MRS. MICHELLE RENEE GANTNER
-----------------------------------------------------
Credential | COTA/L
-----------------------------------------------------
Telephone | 636-379-9106
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 1999137004
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------