Provider Demographics
NPI:1407202740
Name:GENESIS HEALTHCARE, LLC
Entity Type:Organization
Organization Name:GENESIS HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-745-9030
Mailing Address - Street 1:PO BOX 1651
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74702-1651
Mailing Address - Country:US
Mailing Address - Phone:580-745-9030
Mailing Address - Fax:580-745-9069
Practice Address - Street 1:608 BRYAN DR
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-3462
Practice Address - Country:US
Practice Address - Phone:580-745-9030
Practice Address - Fax:580-745-9069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-05
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8060251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health