Provider Demographics
NPI:1629360805
Name:GENESIS CHIROPRACTIC PAIN MANAGEMENT P.C.
Entity Type:Organization
Organization Name:GENESIS CHIROPRACTIC PAIN MANAGEMENT P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAZAL
Authorized Official - Middle Name:JENNIFER
Authorized Official - Last Name:SUYNOV
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:646-581-2541
Mailing Address - Street 1:PO BOX 703
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-0703
Mailing Address - Country:US
Mailing Address - Phone:646-581-2541
Mailing Address - Fax:
Practice Address - Street 1:164 EAST PENN STREET
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561
Practice Address - Country:US
Practice Address - Phone:646-581-2541
Practice Address - Fax:718-301-1804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-06
Last Update Date:2012-12-19
Deactivation Date:2012-09-20
Deactivation Code:
Reactivation Date:2012-12-19
Provider Licenses
StateLicense IDTaxonomies
NYX011936111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty