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General NPI Number Information
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NPI Number | 1134555311
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Entity Type | Organization
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Legal Business Name | GENESIS RESIDENTIAL CARE CENTER, LLC
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Dates
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Enumeration Date | 09/19/2013
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Last Update Date | 09/19/2013
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Provider Practice Location Address
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Address Line | 236 N MEBANE ST
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City | BURLINGTON
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State | NC
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Zip | 27217-3966
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Country | US
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Telephone | 336-512-2114
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1966
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City | BURLINGTON
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State | NC
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Zip | 27216-1966
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MRS. VIVIAN HAITH TIMMONS
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Credential |
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Telephone | 336-512-2114
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | MHL-001-148
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License Number State | NC
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