Provider Demographics
NPI:1962015818
Name:GENESISCARE LANDMARK IMAGING PC
Entity Type:Organization
Organization Name:GENESISCARE LANDMARK IMAGING PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:T
Authorized Official - Last Name:TRIPLETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-272-5090
Mailing Address - Street 1:2160 COLONIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1410
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:111 HARRISON AVE STE 104
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-1819
Practice Address - Country:US
Practice Address - Phone:405-272-5090
Practice Address - Fax:405-272-5091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-28
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory