Provider Demographics
NPI:1114202611
Name:GENESIS II AGE MANAGEMENT, P.A.
Entity Type:Organization
Organization Name:GENESIS II AGE MANAGEMENT, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:KLINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-419-8748
Mailing Address - Street 1:515 W. MAYFIELD ROAD
Mailing Address - Street 2:SUITE 416
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76014-2085
Mailing Address - Country:US
Mailing Address - Phone:817-419-8748
Mailing Address - Fax:817-419-8788
Practice Address - Street 1:515 W. MAYFIELD ROAD
Practice Address - Street 2:SUITE 416
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76014-2085
Practice Address - Country:US
Practice Address - Phone:817-419-8748
Practice Address - Fax:817-419-8788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-15
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE1000261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service