Healthcare Provider Details

I. General information

NPI: 1083944078
Provider Name (Legal Business Name): GENESIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2010
Last Update Date: 01/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 S VERMONT AVE FL 6
LOS ANGELES CA
90020-1912
US

IV. Provider business mailing address

550 S VERMONT AVE FL 6
LOS ANGELES CA
90020-1912
US

V. Phone/Fax

Practice location:
  • Phone: 213-351-7284
  • Fax:
Mailing address:
  • Phone: 213-351-7284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MISS ERIKA G LUNA
Title or Position: MSW INTERN
Credential:
Phone: 626-457-1055