Provider Demographics
NPI:1184052441
Name:GENESIS EXTRACARE, LLC
Entity type:Organization
Organization Name:GENESIS EXTRACARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-571-1779
Mailing Address - Street 1:3500 S VINE AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-8541
Mailing Address - Country:US
Mailing Address - Phone:972-571-2422
Mailing Address - Fax:903-509-3380
Practice Address - Street 1:3500 S VINE AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-8541
Practice Address - Country:US
Practice Address - Phone:972-571-2422
Practice Address - Fax:903-509-3380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-24
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372600000XNursing Service Related ProvidersAdult CompanionGroup - Single Specialty