Provider Demographics
NPI:1679126320
Name:GENESIS SPORTS PERFORMANCE INC
Entity Type:Organization
Organization Name:GENESIS SPORTS PERFORMANCE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:949-838-6686
Mailing Address - Street 1:22600 LAMBERT ST STE 1204F
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-1623
Mailing Address - Country:US
Mailing Address - Phone:949-838-6686
Mailing Address - Fax:
Practice Address - Street 1:22600 LAMBERT ST STE 1204F
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-1623
Practice Address - Country:US
Practice Address - Phone:949-838-6686
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty