Provider Demographics
NPI:1508211970
Name:4 GENESIS PRIMARY HOME CARE, LLC
Entity Type:Organization
Organization Name:4 GENESIS PRIMARY HOME CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:956-348-4229
Mailing Address - Street 1:9700 N. 23RD ST
Mailing Address - Street 2:9700 N. 23RD ST
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78504-9817
Mailing Address - Country:US
Mailing Address - Phone:956-348-4229
Mailing Address - Fax:956-378-9975
Practice Address - Street 1:9700 N. 23RD ST
Practice Address - Street 2:9700 N. 23RD ST
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78504-9817
Practice Address - Country:US
Practice Address - Phone:956-348-4229
Practice Address - Fax:956-378-9975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-04
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
No251E00000XAgenciesHome Health
No385H00000XRespite Care FacilityRespite CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3803058-01Medicaid