Provider Demographics
NPI:1609383298
Name:GENESIS YOUTH CRISIS CENTER, INC.
Entity Type:Organization
Organization Name:GENESIS YOUTH CRISIS CENTER, INC.
Other - Org Name:RIDGELINE CHILDREN'S SHELTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:RUDDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-622-1907
Mailing Address - Street 1:PO BOX 546
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26302
Mailing Address - Country:US
Mailing Address - Phone:304-622-1907
Mailing Address - Fax:304-623-9346
Practice Address - Street 1:413 CHESTNUT STREET
Practice Address - Street 2:
Practice Address - City:PARSONS
Practice Address - State:WV
Practice Address - Zip Code:26287
Practice Address - Country:US
Practice Address - Phone:304-709-7020
Practice Address - Fax:304-399-9115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-04
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children