Organization
GENESIS FAMILY HOME
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JOHN KENNEDY EDMOND SR. (EXECUTIVE DIRECTOR)
(704) 793-9593
Entity
Organization
Contact information
Practice address
484 COOK ST NW, CONCORD, NC 28025-4441
(704) 793-9593
Mailing address
1036 BRANCHVIEW DR, SUITE, CONCORD, NC 28025-2998
(704) 793-9593
Taxonomy
Speciality
Code
Description
License number
State
322D00000X
Emotionally Disturbed Childrens' Residential Treatment Facility
Primary
MHL-013-096
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
6603333
—
NC
Enumeration date
04/23/2007
Last updated
06/13/2008
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