Healthcare Provider Details

I. General information

NPI: 1568871663
Provider Name (Legal Business Name): GENESIS CLUB HOUSE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2014
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

274 LINCOLN ST
WORCESTER MA
01605-2106
US

IV. Provider business mailing address

274 LINCOLN ST
WORCESTER MA
01605-2106
US

V. Phone/Fax

Practice location:
  • Phone: 508-831-0100
  • Fax: 508-753-1286
Mailing address:
  • Phone: 508-831-0100
  • Fax: 508-753-1286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. KEVIN L BRADLEY
Title or Position: EXECUTIVE DIRECTOR
Credential: M ED
Phone: 508-831-0100