Provider Demographics
NPI:1730243858
Name:GENESIS ENTERPRISES, INC.
Entity type:Organization
Organization Name:GENESIS ENTERPRISES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:WILLOW
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUBEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-384-9934
Mailing Address - Street 1:1463 CAMPBELLSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:KY
Mailing Address - Zip Code:42728-2263
Mailing Address - Country:US
Mailing Address - Phone:270-384-9934
Mailing Address - Fax:270-384-2823
Practice Address - Street 1:1463 CAMPBELLSVILLE RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:KY
Practice Address - Zip Code:42728-2263
Practice Address - Country:US
Practice Address - Phone:270-384-9934
Practice Address - Fax:270-384-2823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY35001239Medicaid
KY183884Medicare Oscar/Certification