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General NPI Number Information
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NPI Number | 1225366313
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Entity Type | Organization
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Legal Business Name | GENESIS HOMES OF JACKSON INC.
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Dates
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Enumeration Date | 11/30/2009
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Last Update Date | 11/30/2009
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Provider Practice Location Address
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Address Line | 6853 HAGUE AVE
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City | JACKSON
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State | MI
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Zip | 49201-8334
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Country | US
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Telephone | 517-782-3280
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Fax |
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Provider Business Mailing Address
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Address Line | 6853 HAGUE AVE
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City | JACKSON
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State | MI
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Zip | 49201-8334
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Country | US
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Telephone | 517-782-3280
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MS. SHELLY S KEINATH
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Credential |
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Telephone | 517-782-3280
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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 | AF380246001
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License Number State | MI
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