Provider Demographics
NPI:1578857942
Name:GENESIS REHABILITATION SERVICE
Entity Type:Organization
Organization Name:GENESIS REHABILITATION SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OTR/L PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DOHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-391-5400
Mailing Address - Street 1:2 PENDANT CT
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-6304
Mailing Address - Country:US
Mailing Address - Phone:978-807-7847
Mailing Address - Fax:
Practice Address - Street 1:200 GOVERNORS AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-1644
Practice Address - Country:US
Practice Address - Phone:781-391-5400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-02
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3314314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility