Healthcare Provider Details

I. General information

NPI: 1548148588
Provider Name (Legal Business Name): GENESIS ASSISTED LIVING L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2025
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14138 CRUTCHFIELD CT FL 34219
PARRISH FL
34219-9408
US

IV. Provider business mailing address

5352 ROCKY COAST PL
PALMETTO FL
34221-1423
US

V. Phone/Fax

Practice location:
  • Phone: 813-270-4583
  • Fax:
Mailing address:
  • Phone: 941-545-6797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State

VIII. Authorized Official

Name: DJOUDLIN GERMINAL
Title or Position: ADMINISTRATOR
Credential:
Phone: 941-545-6797