Provider Demographics
NPI:1104044353
Name:GENESIS FAMILY HOME
Entity Type:Organization
Organization Name:GENESIS FAMILY HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:KENNEDY
Authorized Official - Last Name:EDMOND
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:704-793-9593
Mailing Address - Street 1:1036 BRANCHVIEW DR
Mailing Address - Street 2:SUITE
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2998
Mailing Address - Country:US
Mailing Address - Phone:704-793-9593
Mailing Address - Fax:
Practice Address - Street 1:484 COOK ST NW
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-4441
Practice Address - Country:US
Practice Address - Phone:704-793-9593
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-013-096322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603333Medicaid