Provider Demographics
NPI:1760763692
Name:GENOMA MEDICAL & REHABILITATION CENTER, INC.
Entity Type:Organization
Organization Name:GENOMA MEDICAL & REHABILITATION CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/MASSAGE THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYDEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:305-834-5695
Mailing Address - Street 1:6555 NW 36TH ST STE 116117
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33166-6978
Mailing Address - Country:US
Mailing Address - Phone:305-874-2229
Mailing Address - Fax:305-874-2229
Practice Address - Street 1:6555 NW 36TH ST STE 116117
Practice Address - Street 2:
Practice Address - City:VIRGINIA GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33166-6978
Practice Address - Country:US
Practice Address - Phone:305-874-2229
Practice Address - Fax:305-874-2229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 63085261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy