Healthcare Provider Details

I. General information

NPI: 1770977290
Provider Name (Legal Business Name): GENESIS COMPANION SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2015
Last Update Date: 01/13/2023
Certification Date: 01/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 ARLINGTON EXPY STE B105
JACKSONVILLE FL
32211-0810
US

IV. Provider business mailing address

15865 LEXINGTON PARK BLVD
JACKSONVILLE FL
32218-8148
US

V. Phone/Fax

Practice location:
  • Phone: 904-675-0778
  • Fax: 904-212-2591
Mailing address:
  • Phone: 904-405-5614
  • Fax: 904-212-2591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: TANISA SCIPPIO
Title or Position: OWNER
Credential:
Phone: 904-405-5614