Provider Demographics
NPI:1831265495
Name:GENESIS HOUSE, INC
Entity type:Organization
Organization Name:GENESIS HOUSE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KESTER
Authorized Official - Middle Name:VORETT
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-552-5295
Mailing Address - Street 1:1149 WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-7512
Mailing Address - Country:US
Mailing Address - Phone:707-552-5295
Mailing Address - Fax:707-552-3394
Practice Address - Street 1:1149 WARREN AVE
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94591-7512
Practice Address - Country:US
Practice Address - Phone:707-552-5295
Practice Address - Fax:707-552-3394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA480005AN324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility