Provider Demographics
NPI:1083676480
Name:GENESIS MEDICAL PRACTICE, INC.
Entity Type:Organization
Organization Name:GENESIS MEDICAL PRACTICE, INC.
Other - Org Name:GENESIS
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:VELAZQUEZ PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-285-2415
Mailing Address - Street 1:PO BOX 890
Mailing Address - Street 2:MCS 549
Mailing Address - City:HUMACAO
Mailing Address - State:PR
Mailing Address - Zip Code:00792-0890
Mailing Address - Country:US
Mailing Address - Phone:787-285-2415
Mailing Address - Fax:787-285-4590
Practice Address - Street 1:14 CALLE MIGUEL CASILLAS
Practice Address - Street 2:
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791-3638
Practice Address - Country:US
Practice Address - Phone:787-285-2415
Practice Address - Fax:787-285-4590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-03
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service