Provider Demographics
NPI:1093727893
Name:GENESISHOUSE, INC.
Entity Type:Organization
Organization Name:GENESISHOUSE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KELVIN
Authorized Official - Middle Name:FERNANDEZ
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-852-3778
Mailing Address - Street 1:PO BOX 551389
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28055-1389
Mailing Address - Country:US
Mailing Address - Phone:704-852-3778
Mailing Address - Fax:704-853-8751
Practice Address - Street 1:549 COX RD
Practice Address - Street 2:SUITE A
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-0628
Practice Address - Country:US
Practice Address - Phone:704-852-3778
Practice Address - Fax:704-853-8751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9401389103TP0016X
251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase ManagementGroup - Single Specialty
No103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300892Medicaid
NC8300892BMedicaid
NC3418147Medicaid
NC6102216Medicaid
NC8303041RMedicaid
NC8303041Medicaid
NC8300892VMedicaid
NC8300892GMedicaid