Provider Demographics
NPI:1518124783
Name:GENESIS HOUSE BLOOMSBURG
Entity Type:Organization
Organization Name:GENESIS HOUSE BLOOMSBURG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OUTPATIENT SERVICES CCO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:DESANTO
Authorized Official - Suffix:
Authorized Official - Credentials:LSW CCOPD
Authorized Official - Phone:370-322-0520
Mailing Address - Street 1:320 EAST SECOND STREET
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815
Mailing Address - Country:US
Mailing Address - Phone:570-784-4073
Mailing Address - Fax:570-704-4592
Practice Address - Street 1:320 EAST SECOND STREET
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815
Practice Address - Country:US
Practice Address - Phone:570-784-4073
Practice Address - Fax:570-704-4592
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESIS HOUSE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA197052261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007283800Medicaid