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General NPI Number Information
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NPI Number | 1245383447
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Entity Type | Organization
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Legal Business Name | GENESIS HOUSE RECOVERY RESIDENCE INC.
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Dates
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Enumeration Date | 01/19/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 4865 40TH WAY S
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City | LAKE WORTH
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State | FL
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Zip | 33461-5301
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Country | US
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Telephone | 561-439-4070
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Fax | 561-439-4864
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Provider Business Mailing Address
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Address Line | 4865 40TH WAY S
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City | LAKE WORTH
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State | FL
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Zip | 33461-5301
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Country | US
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Telephone | 561-439-4070
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Fax | 561-439-4864
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Authorized Official
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Title or Position | EXEUTIVE DIRECTOR
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Name | MR. JAMES ANTHONY DODGE
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Credential |
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Telephone | 561-439-4070
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 0950AD652501
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License Number State | FL
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