Provider Demographics
NPI:1245383447
Name:GENESIS HOUSE RECOVERY RESIDENCE INC.
Entity Type:Organization
Organization Name:GENESIS HOUSE RECOVERY RESIDENCE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:DODGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-439-4070
Mailing Address - Street 1:4865 40TH WAY S
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-5301
Mailing Address - Country:US
Mailing Address - Phone:561-439-4070
Mailing Address - Fax:561-439-4864
Practice Address - Street 1:4865 40TH WAY S
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-5301
Practice Address - Country:US
Practice Address - Phone:561-439-4070
Practice Address - Fax:561-439-4864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0950AD652501324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility