Provider Demographics
NPI:1497882195
Name:GENESIS THERAPEUTIC SERVICES, INC.
Entity Type:Organization
Organization Name:GENESIS THERAPEUTIC SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KENDRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-577-8200
Mailing Address - Street 1:99 VILLAGE DR STE 12
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-7060
Mailing Address - Country:US
Mailing Address - Phone:910-577-8200
Mailing Address - Fax:910-577-8270
Practice Address - Street 1:99 VILLAGE DR STE 12
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-7060
Practice Address - Country:US
Practice Address - Phone:910-577-8200
Practice Address - Fax:910-577-8270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-067-165320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300859GMedicaid
NC8300858GMedicaid
NC8300859BMedicaid
NC8300858BMedicaid
NC3409583Medicaid
NC8300858Medicaid
NC8300859Medicaid