Provider Demographics
NPI:1932343019
Name:GENESIS HOUSE, INC
Entity Type:Organization
Organization Name:GENESIS HOUSE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KELVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-852-3778
Mailing Address - Street 1:1528 UNION RD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2200
Mailing Address - Country:US
Mailing Address - Phone:704-852-3778
Mailing Address - Fax:704-853-8751
Practice Address - Street 1:759 THUNDER RD
Practice Address - Street 2:
Practice Address - City:SPINDALE
Practice Address - State:NC
Practice Address - Zip Code:28160-1160
Practice Address - Country:US
Practice Address - Phone:828-288-8801
Practice Address - Fax:828-288-8803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-21
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8302550BMedicaid