Provider Demographics
NPI:1588163562
Name:GENERATION 5 HEALTHCARE, INC.
Entity type:Organization
Organization Name:GENERATION 5 HEALTHCARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:TYSON-FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:BSN, RN, CM/DN
Authorized Official - Phone:443-824-0966
Mailing Address - Street 1:P.O. BOX 43
Mailing Address - Street 2:
Mailing Address - City:WHITE MARSH
Mailing Address - State:MD
Mailing Address - Zip Code:21162
Mailing Address - Country:US
Mailing Address - Phone:443-824-0966
Mailing Address - Fax:
Practice Address - Street 1:707 BELGIAN AVE.
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218
Practice Address - Country:US
Practice Address - Phone:443-824-0966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities