Healthcare Provider Details

I. General information

NPI: 1174380463
Provider Name (Legal Business Name): GENESIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 03/04/2024
Certification Date: 03/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 W BROADWAY AVE
MINNEAPOLIS MN
55411-2503
US

IV. Provider business mailing address

2143 ALBEMARLE CT N
ROSEVILLE MN
55113-6677
US

V. Phone/Fax

Practice location:
  • Phone: 952-221-9987
  • Fax: 612-486-8694
Mailing address:
  • Phone: 952-221-9987
  • Fax: 612-486-8694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name: WILMA DENISE KING
Title or Position: PRESIDENT
Credential:
Phone: 612-408-9084