Provider Demographics
NPI:1912685330
Name:GENESIS COMMUNITY SUPPORT SERVICES, LLC
Entity Type:Organization
Organization Name:GENESIS COMMUNITY SUPPORT SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-491-9983
Mailing Address - Street 1:624 GUILFORD COLLEGE RD STE E
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27409-2096
Mailing Address - Country:US
Mailing Address - Phone:336-382-9618
Mailing Address - Fax:
Practice Address - Street 1:624 GUILFORD COLLEGE RD STE E
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27409-2096
Practice Address - Country:US
Practice Address - Phone:336-382-9618
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-06
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health