Provider Demographics
NPI:1023526209
Name:GENESIS REHABILITATION CENTER, LLC
Entity type:Organization
Organization Name:GENESIS REHABILITATION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:CADC II, CCDS
Authorized Official - Phone:213-739-9982
Mailing Address - Street 1:3440 WILSHIRE BLVD STE 909
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-2101
Mailing Address - Country:US
Mailing Address - Phone:213-739-9982
Mailing Address - Fax:213-739-9983
Practice Address - Street 1:3440 WILSHIRE BLVD STE 909
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-2101
Practice Address - Country:US
Practice Address - Phone:213-739-9982
Practice Address - Fax:213-739-9983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-22
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190039AP101YA0400X
324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty