Healthcare Provider Details

I. General information

NPI: 1457894438
Provider Name (Legal Business Name): GENESIS TREATMENT FOSTER CARE AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2016
Last Update Date: 11/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3920 W ANN RD SUITE 100
NORTH LAS VEGAS NV
89031-3839
US

IV. Provider business mailing address

3920 W ANN RD SUITE 100
NORTH LAS VEGAS NV
89031-3839
US

V. Phone/Fax

Practice location:
  • Phone: 702-550-6700
  • Fax: 702-550-4872
Mailing address:
  • Phone: 702-550-6700
  • Fax: 702-550-4872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State

VIII. Authorized Official

Name: CURTIS STUCKEY
Title or Position: PROGRAM COORDINATOR
Credential:
Phone: 702-544-0763