Provider Demographics
NPI:1972110310
Name:GENESIS IN HOME CARE LLC
Entity type:Organization
Organization Name:GENESIS IN HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-389-1943
Mailing Address - Street 1:4711 GOODFELLOW BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63120-1516
Mailing Address - Country:US
Mailing Address - Phone:314-389-1943
Mailing Address - Fax:314-389-7117
Practice Address - Street 1:4711 GOODFELLOW BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63120-1516
Practice Address - Country:US
Practice Address - Phone:314-389-1943
Practice Address - Fax:314-389-7117
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESIS IN HOME CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1029217357Medicaid
MOM285822805Medicaid