Provider Demographics
NPI:1083935746
Name:GENESIS HEALTHCARE CENTER, INC
Entity Type:Organization
Organization Name:GENESIS HEALTHCARE CENTER, INC
Other - Org Name:GENESIS HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-888-1616
Mailing Address - Street 1:1201 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-3822
Mailing Address - Country:US
Mailing Address - Phone:562-591-7621
Mailing Address - Fax:562-591-3292
Practice Address - Street 1:1201 WALNUT AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-3822
Practice Address - Country:US
Practice Address - Phone:562-591-7621
Practice Address - Fax:562-591-3292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-17
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA940000173314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA940000173OtherLICENSE NUMBER
CA555010Medicare Oscar/Certification