Provider Demographics
NPI:1831974955
Name:GENESIS ADULT FAMILY HOME LLC
Entity type:Organization
Organization Name:GENESIS ADULT FAMILY HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-853-1344
Mailing Address - Street 1:3315 W BURGUNDY CT
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5202
Mailing Address - Country:US
Mailing Address - Phone:262-853-1344
Mailing Address - Fax:
Practice Address - Street 1:3315 W BURGUNDY CT
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5202
Practice Address - Country:US
Practice Address - Phone:262-853-1344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
No251J00000XAgenciesNursing Care
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric