Provider Demographics
NPI:1275820110
Name:GENESYS PHO LLC
Entity Type:Organization
Organization Name:GENESYS PHO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:
Authorized Official - Last Name:KUMMLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-424-2025
Mailing Address - Street 1:3495 S CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1455
Mailing Address - Country:US
Mailing Address - Phone:810-424-2136
Mailing Address - Fax:810-249-4149
Practice Address - Street 1:3495 S CENTER RD
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48519-1455
Practice Address - Country:US
Practice Address - Phone:810-424-2201
Practice Address - Fax:810-743-1099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-29
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management