=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366308231
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENESIS REVITALIZATION GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2026
-----------------------------------------------------
Last Update Date | 01/09/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16 S RHODE ISLAND AVE
-----------------------------------------------------
City | ATLANTIC CITY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08401-7759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-335-7373
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 S RHODE ISLAND AVE
-----------------------------------------------------
City | ATLANTIC CITY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08401-7759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-335-7373
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REGINAL ADMINISTRATOR
-----------------------------------------------------
Name | DR. FRANK MCCOY GILLIAM JR.
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 609-892-7681
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 373H00000X
-----------------------------------------------------
Taxonomy Name | Day Training/Habilitation Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------