Provider Demographics
NPI:1447799242
Name:GENESIS FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:GENESIS FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:C
Authorized Official - Last Name:CHANMUGAM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:386-218-2353
Mailing Address - Street 1:1133 SAXON BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8425
Mailing Address - Country:US
Mailing Address - Phone:386-218-2353
Mailing Address - Fax:386-228-9701
Practice Address - Street 1:800 S NOVA RD
Practice Address - Street 2:SUITE I
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-9048
Practice Address - Country:US
Practice Address - Phone:386-676-9300
Practice Address - Fax:386-676-9050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-14
Last Update Date:2022-11-28
Deactivation Date:2018-04-09
Deactivation Code:
Reactivation Date:2018-04-17
Provider Licenses
StateLicense IDTaxonomies
FLOS8600208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty