Provider Demographics
NPI:1386022341
Name:GENESIS SUPORTIVE LIVING
Entity Type:Organization
Organization Name:GENESIS SUPORTIVE LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT OFFICE SUPPORT
Authorized Official - Prefix:
Authorized Official - First Name:XAVIER
Authorized Official - Middle Name:
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-562-2567
Mailing Address - Street 1:1545 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53205-2347
Mailing Address - Country:US
Mailing Address - Phone:414-562-2567
Mailing Address - Fax:414-264-7778
Practice Address - Street 1:1545 N 7TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53205-2347
Practice Address - Country:US
Practice Address - Phone:414-562-2567
Practice Address - Fax:414-264-7778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health