Provider Demographics
NPI:1104150580
Name:GENESIS HEALTHCARE SYSTEM
Entity type:Organization
Organization Name:GENESIS HEALTHCARE SYSTEM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FINCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-902-5588
Mailing Address - Street 1:11760 CENTRAL AVE STE 125
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-1909
Mailing Address - Country:US
Mailing Address - Phone:909-502-5588
Mailing Address - Fax:909-902-1013
Practice Address - Street 1:11760 CENTRAL AVE STE 125
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-1909
Practice Address - Country:US
Practice Address - Phone:909-502-5588
Practice Address - Fax:909-902-1013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-01
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
34087261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ04363ZMedicare PIN