Provider Demographics
NPI:1528138393
Name:GENESIS PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:GENESIS PHYSICAL THERAPY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:N.
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-325-8838
Mailing Address - Street 1:6343 E MAIN ST
Mailing Address - Street 2:SUITE 8
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-8954
Mailing Address - Country:US
Mailing Address - Phone:480-325-8838
Mailing Address - Fax:480-325-9191
Practice Address - Street 1:6343 E MAIN ST
Practice Address - Street 2:SUITE 8
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-8954
Practice Address - Country:US
Practice Address - Phone:480-325-8838
Practice Address - Fax:480-325-9191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC4110261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ698269Medicaid
AZ200152Medicaid
AZ698269Medicaid