Provider Demographics
NPI:1942803994
Name:GENESIS GRACE HOME INC
Entity Type:Organization
Organization Name:GENESIS GRACE HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EVELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:AWUNDAGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:164-673-0024
Mailing Address - Street 1:442 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1246
Mailing Address - Country:US
Mailing Address - Phone:646-730-0249
Mailing Address - Fax:
Practice Address - Street 1:442 BROADWAY
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-1246
Practice Address - Country:US
Practice Address - Phone:646-730-0249
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No251E00000XAgenciesHome Health
No251G00000XAgenciesHospice Care, Community Based
No251J00000XAgenciesNursing Care
No251S00000XAgenciesCommunity/Behavioral Health
No253Z00000XAgenciesIn Home Supportive Care
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No385H00000XRespite Care FacilityRespite Care
No385HR2050XRespite Care FacilityRespite CareRespite Care Camp
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child