Provider Demographics
NPI:1508620501
Name:ASENCIO, GENESIS
Entity Type:Individual
Prefix:
First Name:GENESIS
Middle Name:
Last Name:ASENCIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10801 6TH ST STE 120
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5987
Mailing Address - Country:US
Mailing Address - Phone:800-440-4347
Mailing Address - Fax:
Practice Address - Street 1:10801 6TH ST STE 120
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5987
Practice Address - Country:US
Practice Address - Phone:800-440-4347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-09
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker