Provider Demographics
NPI:1346335288
Name:FIRST GENESIS GROUP HOME INC
Entity Type:Organization
Organization Name:FIRST GENESIS GROUP HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMBERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-274-4447
Mailing Address - Street 1:1903 DELMAR DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-6113
Mailing Address - Country:US
Mailing Address - Phone:336-274-4447
Mailing Address - Fax:336-323-0062
Practice Address - Street 1:1903 DELMAR DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-6113
Practice Address - Country:US
Practice Address - Phone:336-274-4447
Practice Address - Fax:336-852-6400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-041-728322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603817Medicaid