Healthcare Provider Details

I. General information

NPI: 1093727893
Provider Name (Legal Business Name): GENESISHOUSE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 06/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

549 COX RD SUITE A
GASTONIA NC
28054-0628
US

IV. Provider business mailing address

PO BOX 551389
GASTONIA NC
28055-1389
US

V. Phone/Fax

Practice location:
  • Phone: 704-852-3778
  • Fax: 704-853-8751
Mailing address:
  • Phone: 704-852-3778
  • Fax: 704-853-8751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number9401389
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. KELVIN FERNANDEZ HALL
Title or Position: PRESIDENT
Credential:
Phone: 704-852-3778