Provider Demographics
NPI:1013231117
Name:GENESIS COMMUNITY RESOURCE CENTER
Entity Type:Organization
Organization Name:GENESIS COMMUNITY RESOURCE CENTER
Other - Org Name:GENESIS HOME HEALTH CARE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANDA
Authorized Official - Middle Name:RENA
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-884-1402
Mailing Address - Street 1:320 W RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46408-2735
Mailing Address - Country:US
Mailing Address - Phone:219-884-1402
Mailing Address - Fax:
Practice Address - Street 1:11616 BARBERRY CT
Practice Address - Street 2:
Practice Address - City:SAINT JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373-9690
Practice Address - Country:US
Practice Address - Phone:708-654-6324
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-17
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities