Provider Demographics
NPI:1790062594
Name:GENESIS REHAB SERVICES LLC
Entity Type:Organization
Organization Name:GENESIS REHAB SERVICES LLC
Other - Org Name:GENESIS REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARRU
Authorized Official - Middle Name:
Authorized Official - Last Name:MALIK
Authorized Official - Suffix:
Authorized Official - Credentials:MHS, PT
Authorized Official - Phone:219-616-5727
Mailing Address - Street 1:9430 WICKER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-9768
Mailing Address - Country:US
Mailing Address - Phone:219-616-5727
Mailing Address - Fax:
Practice Address - Street 1:9430 WICKER AVE
Practice Address - Street 2:1534 119TH STREET
Practice Address - City:SAINT JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373-9768
Practice Address - Country:US
Practice Address - Phone:219-655-5285
Practice Address - Fax:219-655-5472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-08
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM100076337Medicare PIN