MEDICARE: GENESIS REHAB SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1790062594
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENESIS REHAB SERVICES LLC

Provider Business Mailing Address
First Line	:	9430 WICKER AVE
Second Line	:
City	:	SAINT JOHN
State	:	IN
Zip	:	46373-9768
Country	:	US
Telephone Number	:	219-616-5727
Fax Number	:

Provider Business Practice Location Address
First Line	:	9430 WICKER AVE
Second Line	:	1534 119TH STREET
City	:	SAINT JOHN
State	:	IN
Zip	:	46373-9768
Country	:	US
Telephone Number	:	219-655-5285
Fax Number	:	219-655-5472

Authorized Official
Title or Position	:	SOLE MBR
Name	:	MRS. CHARRU MALIK
Credential	:	M.H.S, P.T.
Telephone Number	:	219-616-5727

Provider Enumeration Date	:	11/08/2011
Last Update Date	:	05/04/2017

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