Provider Demographics
NPI:1194043414
Name:GENESIS
Entity Type:Organization
Organization Name:GENESIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OTR/L
Authorized Official - Prefix:
Authorized Official - First Name:PAMMELA
Authorized Official - Middle Name:EMILY
Authorized Official - Last Name:PIITS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-978-9966
Mailing Address - Street 1:50 KELLY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-3120
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 EMERSON DR
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095-3204
Practice Address - Country:US
Practice Address - Phone:860-640-6317
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-11
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002198314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility