Provider Demographics
NPI:1255824777
Name:GENESIS WELLNESS GROUP LLC
Entity Type:Organization
Organization Name:GENESIS WELLNESS GROUP LLC
Other - Org Name:GENESIS WELLNESS GROUP LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF WELLNESS COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:GENESIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-316-1280
Mailing Address - Street 1:3450 WAYNE AVE APT 14A
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2515
Mailing Address - Country:US
Mailing Address - Phone:171-831-6128
Mailing Address - Fax:
Practice Address - Street 1:65 BROADWAY STE 1602
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10006-2576
Practice Address - Country:US
Practice Address - Phone:718-316-1280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-09
Last Update Date:2018-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038095-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty