Provider Demographics
NPI:1043699739
Name:GENESISDWISERVICES
Entity Type:Organization
Organization Name:GENESISDWISERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:DOCKERY
Authorized Official - Suffix:
Authorized Official - Credentials:CSAC-I
Authorized Official - Phone:919-321-6643
Mailing Address - Street 1:35 W DAVIE ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27601-1732
Mailing Address - Country:US
Mailing Address - Phone:919-321-6643
Mailing Address - Fax:919-321-8930
Practice Address - Street 1:35 W DAVIE ST
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27601-1732
Practice Address - Country:US
Practice Address - Phone:919-321-6643
Practice Address - Fax:919-321-8930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-27
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health