Provider Demographics
NPI:1417406513
Name:GENESIS FAMILY MEDICINE & AESTHETICS, LLC
Entity Type:Organization
Organization Name:GENESIS FAMILY MEDICINE & AESTHETICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARIBEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAVEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-262-8242
Mailing Address - Street 1:7316 SPOUT SPRINGS RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-5665
Mailing Address - Country:US
Mailing Address - Phone:678-262-8242
Mailing Address - Fax:
Practice Address - Street 1:7316 SPOUT SPRINGS RD
Practice Address - Street 2:SUITE 201
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542-5665
Practice Address - Country:US
Practice Address - Phone:678-262-8242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-29
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA33410207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000647006AMedicaid
GA000647006AMedicaid