Organization
GENESISHOUSE, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. KELVIN FERNANDEZ HALL (PRESIDENT)
(704) 852-3778
Entity
Organization
Contact information
Practice address
549 COX RD, SUITE A, GASTONIA, NC 28054-0628
(704) 852-3778
(704) 853-8751
Mailing address
PO BOX 551389, GASTONIA, NC 28055-1389
(704) 852-3778
(704) 853-8751
Taxonomy
Speciality
Code
Description
License number
State
103TP0016X
Prescribing (Medical) Psychologist
9401389
NC
251B00000X
Case Management Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
3418147
—
NC
05
—
6102216
—
NC
05
—
8300892
—
NC
05
—
8300892B
—
NC
05
—
8300892G
—
NC
05
—
8300892V
—
NC
05
—
8303041
—
NC
05
—
8303041R
—
NC
Enumeration date
08/12/2006
Last updated
06/29/2011
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