Provider Demographics
NPI:1578748158
Name:GENESIS FAMILY CENTER
Entity Type:Organization
Organization Name:GENESIS FAMILY CENTER
Other - Org Name:GENESIS INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PROGRAM COORDINATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:TONGIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:BA SOCIAL WORK
Authorized Official - Phone:559-439-5437
Mailing Address - Street 1:1260 N MARIPOSA
Mailing Address - Street 2:
Mailing Address - City:FRESN0
Mailing Address - State:CA
Mailing Address - Zip Code:93703
Mailing Address - Country:US
Mailing Address - Phone:559-233-3246
Mailing Address - Fax:
Practice Address - Street 1:1260 N MARIPOSA ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-3940
Practice Address - Country:US
Practice Address - Phone:559-233-3246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESIS SUBSTANCE ABUSE SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-02
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100043AN251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00000000OtherMEDI-CAL