Provider Demographics
NPI:1356111710
Name:GENESIS WOMEN'S HEALTH NON-PROFIT CORPORATION
Entity type:Organization
Organization Name:GENESIS WOMEN'S HEALTH NON-PROFIT CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:P
Authorized Official - Last Name:VENESKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:832-282-6260
Mailing Address - Street 1:378 S RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-4115
Mailing Address - Country:US
Mailing Address - Phone:208-306-0700
Mailing Address - Fax:208-759-7187
Practice Address - Street 1:378 S RIDGE AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-4115
Practice Address - Country:US
Practice Address - Phone:208-306-0700
Practice Address - Fax:208-759-7187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-08
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthingGroup - Single Specialty