Provider Demographics
NPI:1467746560
Name:GENESI LLC
Entity Type:Organization
Organization Name:GENESI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSLER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSANNE
Authorized Official - Middle Name:JILL
Authorized Official - Last Name:NARDONI ISOM
Authorized Official - Suffix:
Authorized Official - Credentials:LLC
Authorized Official - Phone:405-703-8755
Mailing Address - Street 1:9210 S WESTERN AVE
Mailing Address - Street 2:A-21
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-2734
Mailing Address - Country:US
Mailing Address - Phone:405-703-8755
Mailing Address - Fax:405-895-7544
Practice Address - Street 1:9210 S WESTERN AVE
Practice Address - Street 2:A-21
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-2734
Practice Address - Country:US
Practice Address - Phone:405-703-8755
Practice Address - Fax:405-895-7544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-06
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3512256863251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health