Provider Demographics
NPI:1659683936
Name:GENESIS
Entity Type:Organization
Organization Name:GENESIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED OCCUPATIONAL THERAPIS
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:TICE
Authorized Official - Suffix:
Authorized Official - Credentials:COTA/L
Authorized Official - Phone:330-424-1504
Mailing Address - Street 1:44755 MIDDLE BEAVER RD
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:OH
Mailing Address - Zip Code:44432-9556
Mailing Address - Country:US
Mailing Address - Phone:330-424-1504
Mailing Address - Fax:
Practice Address - Street 1:2511 BENTLEY DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OH
Practice Address - Zip Code:44460-2503
Practice Address - Country:US
Practice Address - Phone:330-337-3015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-02
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1087314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility