Provider Demographics
NPI:1336470616
Name:GENESIS HEALTH AND WELLNESS LLC
Entity Type:Organization
Organization Name:GENESIS HEALTH AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:P
Authorized Official - Last Name:TYMCHAK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:812-858-1005
Mailing Address - Street 1:8211 W STATE ROUTE 66
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-2534
Mailing Address - Country:US
Mailing Address - Phone:812-858-1005
Mailing Address - Fax:812-858-1001
Practice Address - Street 1:8211 W STATE ROUTE 66
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-2534
Practice Address - Country:US
Practice Address - Phone:812-858-1005
Practice Address - Fax:812-858-1001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-26
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002011A133NN1002X, 332BC3200X
208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201085220AMedicaid
IN6480930001Medicare NSC