Provider Demographics
NPI:1346672912
Name:GENESIS DEVELOPMENTAL SERVICES
Entity Type:Organization
Organization Name:GENESIS DEVELOPMENTAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEVELOPMENTAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:IVIS
Authorized Official - Middle Name:S
Authorized Official - Last Name:FUENTES
Authorized Official - Suffix:
Authorized Official - Credentials:ITFS
Authorized Official - Phone:919-437-2156
Mailing Address - Street 1:123 HARRIS RD
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27577-8161
Mailing Address - Country:US
Mailing Address - Phone:919-437-2156
Mailing Address - Fax:
Practice Address - Street 1:123 HARRIS RD
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-8161
Practice Address - Country:US
Practice Address - Phone:919-437-2156
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-06
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCITFS222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty