Provider Demographics
NPI:1437666765
Name:GENESIS THERAPEUTICS INC
Entity Type:Organization
Organization Name:GENESIS THERAPEUTICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAKESPEARE
Authorized Official - Middle Name:
Authorized Official - Last Name:NGO
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:917-724-1018
Mailing Address - Street 1:6402 DEWEY AVE APT 13
Mailing Address - Street 2:
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-3090
Mailing Address - Country:US
Mailing Address - Phone:917-724-1018
Mailing Address - Fax:
Practice Address - Street 1:6402 DEWEY AVE APT 13
Practice Address - Street 2:
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-3090
Practice Address - Country:US
Practice Address - Phone:917-724-1018
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-09
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017925-1225100000X
FL0008162225100000X
LA01578F225100000X
NC5004225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY395780OtherNYS EI DOH ID NUMBER
NY017925-1OtherNYS PT LICENSE NUMBER