MEDICARE: GENESIS CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	315P00000X	Intellectual Disabilities Intermediate Care Facility		CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023004561
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENESIS CORPORATION

Provider Business Mailing Address
First Line	:	PO BOX 626
Second Line	:
City	:	PISMO BEACH
State	:	CA
Zip	:	93448-0626
Country	:	US
Telephone Number	:	805-489-9472
Fax Number	:	805-474-6893

Provider Business Practice Location Address
First Line	:	17096 VIA FLORES
Second Line	:
City	:	SAN LORENZO
State	:	CA
Zip	:	94580-2915
Country	:	US
Telephone Number	:	510-276-8442
Fax Number	:	510-276-7802

Authorized Official
Title or Position	:	CONTROLLER
Name	:	MS. PAMELA GRAHAM
Credential	:
Telephone Number	:	805-489-9472

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	08/22/2020

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Directions to “GENESIS CORPORATION ” Practice Location

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