Provider Demographics
NPI:1285965004
Name:GENESIS43 LLC
Entity type:Organization
Organization Name:GENESIS43 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SEGUNDO
Authorized Official - Middle Name:I
Authorized Official - Last Name:BALDOVINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-552-4300
Mailing Address - Street 1:22811 GREATER MACK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2021
Mailing Address - Country:US
Mailing Address - Phone:586-552-4300
Mailing Address - Fax:586-552-4304
Practice Address - Street 1:22811 GREATER MACK AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2021
Practice Address - Country:US
Practice Address - Phone:586-552-4300
Practice Address - Fax:586-552-4304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care