1306004999 NPI number — GENESIS BEHAVIORAL SERVICES, INC.

Table of content: (NPI 1306004999)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306004999 NPI number — GENESIS BEHAVIORAL SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GENESIS BEHAVIORAL SERVICES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306004999
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/04/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12647 OLIVE BLVD
Provider Second Line Business Mailing Address:
ATTN: ACCTS. RECEIVEABLE
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63141-6393
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-777-1570
Provider Business Mailing Address Fax Number:
414-777-1565

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1626 CLARENCE COURT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST BEND
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53095
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-338-8611
Provider Business Practice Location Address Fax Number:
262-338-3367
Provider Enumeration Date:
05/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ORTLOFF
Authorized Official First Name:
PAULINE
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
414-777-1570

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  1465 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 1465 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X , with the licence number: 1465 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 42185921 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 42185900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 42242221 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 42186000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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