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General NPI Number Information
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NPI Number | 1932453347
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Entity Type | Organization
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Legal Business Name | GENESIS REHAB SERVICES
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Dates
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Enumeration Date | 11/07/2012
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Last Update Date | 11/07/2012
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Provider Practice Location Address
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Address Line | 6700 S KEATING AVE
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City | CHICAGO
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State | IL
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Zip | 60629-5660
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Country | US
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Telephone | 773-767-6262
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Fax |
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Provider Business Mailing Address
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Address Line | 2239 BURR OAK AVE
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City | NORTH RIVERSIDE
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State | IL
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Zip | 60546-1317
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Country | US
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Telephone | 708-469-8497
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Fax |
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Authorized Official
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Title or Position | PHYSICAL THERAPIST ASSISTANT
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Name | FERNANDO RODRIGUE
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Credential | PTA
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Telephone | 708-469-8497
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320700000X
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Taxonomy Name | Physical Disabilities Residential Treatment Facility
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License Number | 160005776
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License Number State | IL
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