Provider Demographics
NPI:1629299532
Name:GENESIS FAMILY HOME
Entity Type:Organization
Organization Name:GENESIS FAMILY HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:KENNEDY
Authorized Official - Last Name:EDMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-793-9593
Mailing Address - Street 1:1036 BRANCHVIEW DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2998
Mailing Address - Country:US
Mailing Address - Phone:704-793-9593
Mailing Address - Fax:
Practice Address - Street 1:1036 BRANCHVIEW DR
Practice Address - Street 2:SUITE 201
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2998
Practice Address - Country:US
Practice Address - Phone:704-793-9593
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children