Healthcare Provider Details

I. General information

NPI: 1801293774
Provider Name (Legal Business Name): GENESIS AESTHETICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2014
Last Update Date: 11/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9511 JAGGED CREEK CT
DELRAY BEACH FL
33446-9525
US

IV. Provider business mailing address

9511 JAGGED CREEK CT
DELRAY BEACH FL
33446-9525
US

V. Phone/Fax

Practice location:
  • Phone: 561-325-8530
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberME97906
License Number StateFL

VIII. Authorized Official

Name: CARLOS CEPEDA
Title or Position: MEMBER
Credential:
Phone: 561-325-8530