Provider Demographics
NPI:1568871663
Name:GENESIS CLUB HOUSE, INC.
Entity Type:Organization
Organization Name:GENESIS CLUB HOUSE, INC.
Other - Org Name:GENESIS CLUB, INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:M ED
Authorized Official - Phone:508-831-0100
Mailing Address - Street 1:274 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2106
Mailing Address - Country:US
Mailing Address - Phone:508-831-0100
Mailing Address - Fax:508-753-1286
Practice Address - Street 1:274 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2106
Practice Address - Country:US
Practice Address - Phone:508-831-0100
Practice Address - Fax:508-753-1286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-04
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA=========OtherNON-PROFIT TAX ID NUMBER