Provider Demographics
NPI:1851872832
Name:GENESIS LIVING
Entity Type:Organization
Organization Name:GENESIS LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RITA
Authorized Official - Middle Name:
Authorized Official - Last Name:AGHENTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-955-6535
Mailing Address - Street 1:2839 E COURTNEY ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85298-5735
Mailing Address - Country:US
Mailing Address - Phone:651-955-6535
Mailing Address - Fax:
Practice Address - Street 1:2839 E COURTNEY ST
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85298-5735
Practice Address - Country:US
Practice Address - Phone:651-955-6535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-27
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH54993104A0630X
320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances