Healthcare Provider Details

I. General information

NPI: 1639770274
Provider Name (Legal Business Name): THE GENESIS PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2020
Last Update Date: 11/02/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1104 JOHNSTON ST
AKRON OH
44305-2414
US

IV. Provider business mailing address

1104 JOHNSTON ST
AKRON OH
44305-2414
US

V. Phone/Fax

Practice location:
  • Phone: 330-730-7099
  • Fax:
Mailing address:
  • Phone: 330-730-7099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: SEANLAY MICHAY CAREY
Title or Position: CEO
Credential:
Phone: 330-730-7099