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NPI Code Detail

MEDICARE: GENESIS B VILLANUEVA PT

MEDICARE: GENESIS B VILLANUEVA PT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical TherapistPT27082FL

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1P01016039OTHERFLRR MEDICARE

General Provider Information

NPI Number : 1447521968
Entity Type Code : Individual
Provider Name (Legal Business Name) : GENESIS B VILLANUEVA PT
Provider Business Mailing Address
First Line : PO BOX 40767
Second Line : CREDENTIALING DEPARTMENT
City : JACKSONVILLE
State : FL
Zip : 32203-0767
Country : US
Telephone Number : 904-376-3707
Fax Number : 904-391-5807
Provider Business Practice Location Address
First Line : 12961 N MAIN ST STE 201&202
Second Line : CREDENTIALING DEPARTMENT
City : JACKSONVILLE
State : FL
Zip : 32218-2769
Country : US
Telephone Number : 904-757-2474
Fax Number : 904-757-5541
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/13/2012
Last Update Date : 02/04/2015

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Directions to “ GENESIS B VILLANUEVA PT” Practice Location

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