Provider Demographics
NPI:1376988717
Name:GENESIS REHAB SERVICES
Entity Type:Organization
Organization Name:GENESIS REHAB SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COTA
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:MATHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-310-9411
Mailing Address - Street 1:552 SPANISH WAY W
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-9244
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:552 SPANISH WAY W
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-9244
Practice Address - Country:US
Practice Address - Phone:904-310-9411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-04-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA11456224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty