Provider Demographics
NPI:1760753701
Name:GENESIS INSTITUTO DE SERVICIOS MULTIDISCIPLINARIOS, INC.
Entity Type:Organization
Organization Name:GENESIS INSTITUTO DE SERVICIOS MULTIDISCIPLINARIOS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:IVELISSE
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-374-3230
Mailing Address - Street 1:C1 A4 CONDADO MODERNO
Mailing Address - Street 2:SUITE 7
Mailing Address - City:CAGUAS
Mailing Address - State:PUERTO RICO
Mailing Address - Zip Code:00725
Mailing Address - Country:UM
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:C1A CALLE 4
Practice Address - Street 2:SUITE 7
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725-4613
Practice Address - Country:US
Practice Address - Phone:787-374-3230
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1914103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty