Provider Demographics
NPI:1700021441
Name:GENESIS
Entity Type:Organization
Organization Name:GENESIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:JOANNE
Authorized Official - Last Name:HANNAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-835-6428
Mailing Address - Street 1:700 WALNUT RIDGE DR
Mailing Address - Street 2:3055
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-1000
Mailing Address - Country:US
Mailing Address - Phone:469-835-6428
Mailing Address - Fax:972-871-2740
Practice Address - Street 1:700 WALNUT RIDGE DR
Practice Address - Street 2:3055
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-1000
Practice Address - Country:US
Practice Address - Phone:469-835-6428
Practice Address - Fax:972-871-2740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-09
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX835552171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty