Provider Demographics
NPI:1487958716
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:
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:PO BOX 551389
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28055-1389
Mailing Address - Country:US
Mailing Address - Phone:704-852-3778
Mailing Address - Fax:
Practice Address - Street 1:549 COX RD
Practice Address - Street 2:SUITE A
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-0628
Practice Address - Country:US
Practice Address - Phone:704-852-3778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-30
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase ManagementGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Single Specialty
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300892GMedicaid
NC8303041RMedicaid
NC8702052Medicaid
NC5914113Medicaid
NC6002315Medicaid
NC6005952Medicaid
NC8300892HMedicaid
NC8300892VMedicaid
NC8703125Medicaid
NC8302550Medicaid
NC8302550VMedicaid
NC8921979Medicaid