MEDICARE: THE GENESIS PROJECT

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1275767709
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE GENESIS PROJECT

Provider Business Mailing Address
First Line	:	4441 SIX FORKS RD
Second Line	:	#106-216
City	:	RALEIGH
State	:	NC
Zip	:	27609-5729
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	801 GILBERT ST
Second Line	:	#208
City	:	DURHAM
State	:	NC
Zip	:	27701-3509
Country	:	US
Telephone Number	:	919-251-6196
Fax Number	:

Authorized Official
Title or Position	:	CFO/COO
Name	:	SIMONE MCCREA
Credential	:
Telephone Number	:	919-251-6196

Provider Enumeration Date	:	05/12/2009
Last Update Date	:	06/30/2009

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