Provider Demographics
NPI:1235993155
Name:GENESIS WELLNESS SUPPORT CORP
Entity Type:Organization
Organization Name:GENESIS WELLNESS SUPPORT CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YISCEL MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PASCUAL BERMUDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-740-0516
Mailing Address - Street 1:12651 S DIXIE HWY STE 309
Mailing Address - Street 2:
Mailing Address - City:PINECREST
Mailing Address - State:FL
Mailing Address - Zip Code:33156-5961
Mailing Address - Country:US
Mailing Address - Phone:786-740-0516
Mailing Address - Fax:
Practice Address - Street 1:12651 S DIXIE HWY STE 309
Practice Address - Street 2:
Practice Address - City:PINECREST
Practice Address - State:FL
Practice Address - Zip Code:33156-5961
Practice Address - Country:US
Practice Address - Phone:786-740-0516
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty