Provider Demographics
NPI:1346579398
Name:GENESIS REHABILITATION SERVICES
Entity Type:Organization
Organization Name:GENESIS REHABILITATION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TINNA MARIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOLONGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-679-4006
Mailing Address - Street 1:7120 N SHERIDAN RD
Mailing Address - Street 2:# 201
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-2900
Mailing Address - Country:US
Mailing Address - Phone:773-679-4006
Mailing Address - Fax:
Practice Address - Street 1:7120 N SHERIDAN RD
Practice Address - Street 2:# 201
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-2900
Practice Address - Country:US
Practice Address - Phone:773-679-4006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-21
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070015702310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility