Provider Demographics
NPI:1336273945
Name:GENESIS
Entity Type:Organization
Organization Name:GENESIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:B
Authorized Official - Last Name:KAYE
Authorized Official - Suffix:
Authorized Official - Credentials:LPT
Authorized Official - Phone:336-789-5542
Mailing Address - Street 1:419 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-4635
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2206 RIDGE CREST LN
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-2483
Practice Address - Country:US
Practice Address - Phone:336-786-9132
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4768320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities