Provider Demographics
NPI:1629336359
Name:GENESIS
Entity Type:Organization
Organization Name:GENESIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESPIRATORY THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAVENER
Authorized Official - Suffix:
Authorized Official - Credentials:CRTT
Authorized Official - Phone:850-776-8448
Mailing Address - Street 1:5214 GOSHAWK DR
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32570-5020
Mailing Address - Country:US
Mailing Address - Phone:850-776-8448
Mailing Address - Fax:
Practice Address - Street 1:5214 GOSHAWK DR
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-5020
Practice Address - Country:US
Practice Address - Phone:850-776-8448
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-01
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTT3185313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility