Provider Demographics
NPI:1558603266
Name:GENESIS REHAB SERVICES
Entity Type:Organization
Organization Name:GENESIS REHAB SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:KOURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-374-9574
Mailing Address - Street 1:2649 E 75TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-3835
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2649 E 75TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-3835
Practice Address - Country:US
Practice Address - Phone:773-721-5845
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-20
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160006340314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility