Provider Demographics
NPI:1326825217
Name:GENESIS OUT PATIENT LLC
Entity Type:Organization
Organization Name:GENESIS OUT PATIENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:GATONGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-865-9794
Mailing Address - Street 1:7303 E MAIN ST STE 106
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-8325
Mailing Address - Country:US
Mailing Address - Phone:954-865-9794
Mailing Address - Fax:
Practice Address - Street 1:7303 E MAIN ST STE 106
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85207-8325
Practice Address - Country:US
Practice Address - Phone:954-865-9794
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)