=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508211970
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 4 GENESIS PRIMARY HOME CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2016
-----------------------------------------------------
Last Update Date | 06/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9700 N. 23RD ST 9700 N. 23RD ST
-----------------------------------------------------
City | MCALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78504-9817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-348-4229
-----------------------------------------------------
Fax | 956-378-9975
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9700 N. 23RD ST 9700 N. 23RD ST
-----------------------------------------------------
City | MCALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78504-9817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-348-4229
-----------------------------------------------------
Fax | 956-378-9975
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR-OWNER
-----------------------------------------------------
Name | MR. MANUEL MIRANDA JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 956-348-4229
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 385H00000X
-----------------------------------------------------
Taxonomy Name | Respite Care
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3747P1801X
-----------------------------------------------------
Taxonomy Name | Personal Care Attendant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------