Basic Information
| Provider Information | |||||||||
| NPI: | 1568735744 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GENESIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4329 HAWKSONG PL | ||||||||
| Address2: | |||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275185480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193870878 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6590 TRYON RD | ||||||||
| Address2: | |||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275187052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198518000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2012 | ||||||||
| LastUpdateDate: | 02/17/2012 | ||||||||
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| AuthorizedOfficialLastName: | MATTHEWS | ||||||||
| AuthorizedOfficialFirstName: | IWONNA | ||||||||
| AuthorizedOfficialMiddleName: | MARIA | ||||||||
| AuthorizedOfficialTitleorPosition: | DOR | ||||||||
| AuthorizedOfficialTelephone: | 9198518000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 3368 | NC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.