Healthcare Provider Details

I. General information

NPI: 1932501988
Provider Name (Legal Business Name): GENESIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2014
Last Update Date: 09/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 CANON AVE APT 2
MANITOU SPRINGS CO
80829-2947
US

IV. Provider business mailing address

505 CANON AVE APT 2
MANITOU SPRINGS CO
80829-2947
US

V. Phone/Fax

Practice location:
  • Phone: 248-794-4467
  • Fax:
Mailing address:
  • Phone: 248-794-4467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0000038
License Number StateCO

VIII. Authorized Official

Name: SARA KELI CHARLES
Title or Position: OCCUPATIONAL THERAPY ASSISTANT
Credential: COTA
Phone: 248-794-4467