Healthcare Provider Details

I. General information

NPI: 1942296488
Provider Name (Legal Business Name): GENESIS CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 BARROW ST
SAN LEANDRO CA
94577-3217
US

IV. Provider business mailing address

PO BOX 626
PISMO BEACH CA
93448-0626
US

V. Phone/Fax

Practice location:
  • Phone: 510-352-8537
  • Fax: 510-352-8241
Mailing address:
  • Phone: 805-489-9472
  • Fax: 805-474-6893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number StateCA

VIII. Authorized Official

Name: MS. PAMELA GRAHAM
Title or Position: CONTROLLER
Credential:
Phone: 805-489-9472