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General NPI Number Information
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NPI Number | 1043206576
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Entity Type | Organization
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Legal Business Name | GENESIS CORPORATION
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Dates
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Enumeration Date | 09/20/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 273 MOONCREST LN
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City | SANTA MARIA
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State | CA
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Zip | 93455-3713
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Country | US
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Telephone | 805-937-5224
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Fax | 805-934-0860
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Provider Business Mailing Address
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Address Line | PO BOX 626
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City | PISMO BEACH
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State | CA
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Zip | 93448-0626
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Country | US
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Telephone | 805-489-9472
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Fax | 805-474-6893
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Authorized Official
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Title or Position | CONTROLLER
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Name | MS. PAMELA GRAHAM
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Credential |
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Telephone | 805-489-9472
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number |
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License Number State | CA
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