NPIMap

Organization Active NPI

Genesis Family Home

  • Emotionally Disturbed Childrens' Residential Treatment Facility
  • Concord, NC
National Provider Identifier
1104044353
Registry record updated Jun 13, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Emotionally Disturbed Childrens' Residential Treatment FacilityTaxonomy code 322D00000X
License
MHL-013-096 Issued in NC
Legal business name
GENESIS FAMILY HOME
Practice address
484 Cook St NW
Concord, NC 28025-4441
Phone
(704) 793-9593
NPI assigned
Apr 23, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 13, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. John Kennedy Edmond Sr.
Title
Executive Director
Phone
(704) 793-9593

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Emotionally Disturbed Childrens' Residential Treatment Facility 322D00000X MHL-013-096 NC Primary

Addresses

Primary practice location

484 Cook St NW
Concord, NC 28025-4441

Mailing address

1036 Branchview Dr
Suite
Concord, NC 28025-2998
Phone (704) 793-9593

Other identifiers 1

IdentifierTypeStateIssuer
6603333MedicaidNC

National Provider Directory

National Provider Directory
Tax ID family
Genesis Family Home4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Locations

1036 Branchview Dr
Concord, NC 28025

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1177286400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1213315200000",
    "number": "1104044353",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1036 BRANCHVIEW DR",
            "address_2": "SUITE",
            "city": "CONCORD",
            "state": "NC",
            "postal_code": "280252998",
            "telephone_number": "704-793-9593"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "484 COOK ST NW",
            "city": "CONCORD",
            "state": "NC",
            "postal_code": "280254441",
            "telephone_number": "704-793-9593"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GENESIS FAMILY HOME",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-23",
        "last_updated": "2008-06-13",
        "status": "A",
        "authorized_official_last_name": "EDMOND",
        "authorized_official_first_name": "JOHN",
        "authorized_official_middle_name": "KENNEDY",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "704-793-9593",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_name_suffix": "Sr."
    },
    "taxonomies": [
        {
            "code": "322D00000X",
            "taxonomy_group": "",
            "desc": "Residential Treatment Facility, Emotionally Disturbed Children",
            "state": "NC",
            "license": "MHL-013-096",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "6603333",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Concord, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 13, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.