Provider Demographics
NPI:1023004561
Name:GENESIS CORPORATION
Entity Type:Organization
Organization Name:GENESIS CORPORATION
Other - Org Name:GENESIS DEVELOPMENTAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-489-9472
Mailing Address - Street 1:PO BOX 626
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93448-0626
Mailing Address - Country:US
Mailing Address - Phone:805-489-9472
Mailing Address - Fax:805-474-6893
Practice Address - Street 1:17096 VIA FLORES
Practice Address - Street 2:
Practice Address - City:SAN LORENZO
Practice Address - State:CA
Practice Address - Zip Code:94580-2915
Practice Address - Country:US
Practice Address - Phone:510-276-8442
Practice Address - Fax:510-276-7802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC60739FMedicaid