Provider Demographics
NPI:1225336225
Name:GENESIS HOME CARE LLC
Entity Type:Organization
Organization Name:GENESIS HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CHEVALIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-218-3671
Mailing Address - Street 1:2401 N MAIN ST STE D
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-3581
Mailing Address - Country:US
Mailing Address - Phone:575-218-3671
Mailing Address - Fax:
Practice Address - Street 1:120 W 11TH ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-5806
Practice Address - Country:US
Practice Address - Phone:575-218-3671
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-01
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM61712253Z00000X
3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
No253Z00000XAgenciesIn Home Supportive CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM12855731Medicaid
NM88781038Medicaid