Healthcare Provider Details

I. General information

NPI: 1609383298
Provider Name (Legal Business Name): GENESIS YOUTH CRISIS CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2018
Last Update Date: 01/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 CHESTNUT STREET
PARSONS WV
26287
US

IV. Provider business mailing address

PO BOX 546
CLARKSBURG WV
26302
US

V. Phone/Fax

Practice location:
  • Phone: 304-709-7020
  • Fax: 304-399-9115
Mailing address:
  • Phone: 304-622-1907
  • Fax: 304-623-9346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: EDWARD MATTHEW RUDDER
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 304-622-1907