Healthcare Provider Details

I. General information

NPI: 1578748158
Provider Name (Legal Business Name): GENESIS FAMILY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2008
Last Update Date: 01/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 N MARIPOSA ST
FRESNO CA
93703-3940
US

IV. Provider business mailing address

1260 N MARIPOSA
FRESN0 CA
93703
US

V. Phone/Fax

Practice location:
  • Phone: 559-233-3246
  • Fax:
Mailing address:
  • Phone: 559-233-3246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number100043AN
License Number StateCA

VIII. Authorized Official

Name: MISS TONGIA SULLIVAN
Title or Position: PROGRAM COORDINATOR
Credential: BA SOCIAL WORK
Phone: 559-439-5437