Provider Demographics
NPI:1932453347
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:FERNANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUE
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:708-469-8497
Mailing Address - Street 1:2239 BURR OAK AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-1317
Mailing Address - Country:US
Mailing Address - Phone:708-469-8497
Mailing Address - Fax:
Practice Address - Street 1:6700 S KEATING AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-5660
Practice Address - Country:US
Practice Address - Phone:773-767-6262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AUTUM GREEN VILLAGE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-07
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160005776320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities