Provider Demographics
NPI:1306250675
Name:GENESIS
Entity type:Organization
Organization Name:GENESIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPY
Authorized Official - Prefix:MISS
Authorized Official - First Name:JOELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:ESCOE
Authorized Official - Suffix:
Authorized Official - Credentials:COTA/L
Authorized Official - Phone:918-851-0737
Mailing Address - Street 1:17110 E 51ST STREET
Mailing Address - Street 2:
Mailing Address - City:BROKEN
Mailing Address - State:OK
Mailing Address - Zip Code:74012
Mailing Address - Country:US
Mailing Address - Phone:918-851-0737
Mailing Address - Fax:
Practice Address - Street 1:17110 E 51ST ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-9279
Practice Address - Country:US
Practice Address - Phone:918-851-0737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-16
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK280313M00000X, 320700000X
OKOA280320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities