MEDICARE: GENMAR HOMES, INC.

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	315P00000X	Intellectual Disabilities Intermediate Care Facility	00000	CA

General Provider Information

NPI Number	:	1710334487
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENMAR HOMES, INC.

Provider Business Mailing Address
First Line	:	14901 CONDON AVE
Second Line	:
City	:	LAWNDALE
State	:	CA
Zip	:	90260-1216
Country	:	US
Telephone Number	:	323-755-7105
Fax Number	:	323-755-7106

Provider Business Practice Location Address
First Line	:	1942 THOREAU ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90047-4725
Country	:	US
Telephone Number	:	323-755-7105
Fax Number	:	323-755-7106

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	DR. EUGENE HARDIN
Credential	:	M.D.
Telephone Number	:	310-739-3585

Provider Enumeration Date	:	05/23/2016
Last Update Date	:	05/23/2016

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Directions to “GENMAR HOMES, INC. ” Practice Location

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