Provider Demographics
NPI:1932571528
Name:GENESIS REHAB SERVICES
Entity Type:Organization
Organization Name:GENESIS REHAB SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PTA/DOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GRETA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-863-9551
Mailing Address - Street 1:306 E. NIZHONI BLVD.
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301
Mailing Address - Country:US
Mailing Address - Phone:505-863-9551
Mailing Address - Fax:
Practice Address - Street 1:306 E NIZHONI BLVD
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5794
Practice Address - Country:US
Practice Address - Phone:505-863-9551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-22
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-0411310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM=========Medicaid