MEDICARE: FIRST GENESIS GROUP HOME (DBA) BISBEE PLACE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	4173	NC
2	101YP2500X	Professional Counselor	0701003386	VA
3	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	041837	NC

General Provider Information

NPI Number	:	1528255767
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIRST GENESIS GROUP HOME (DBA) BISBEE PLACE

Provider Business Mailing Address
First Line	:	4309 PENTON PLACE
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27455-1920
Country	:	US
Telephone Number	:	336-292-1555
Fax Number	:	336-274-6608

Provider Business Practice Location Address
First Line	:	4821 BISBEE DR
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27407-9710
Country	:	US
Telephone Number	:	336-292-1555
Fax Number	:	336-274-6608

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DR. JANICE M CHAMBERS
Credential	:	LPC
Telephone Number	:	336-292-1555

Provider Enumeration Date	:	10/02/2007
Last Update Date	:	10/03/2011

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