Healthcare Provider Details

I. General information

NPI: 1972928455
Provider Name (Legal Business Name): GENOMA HOME HEALTH CARE AGENCY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2014
Last Update Date: 02/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1499 FOREST HILL BLVD SUITE 106
LAKE CLARKE SHORES FL
33406-6050
US

IV. Provider business mailing address

1499 FOREST HILL BLVD SUITE 106
LAKE CLARKE SHORES FL
33406-6050
US

V. Phone/Fax

Practice location:
  • Phone: 561-410-5622
  • Fax: 561-410-5621
Mailing address:
  • Phone: 561-410-5622
  • Fax: 561-410-5621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: RAYDEL MIRANDA
Title or Position: PRESIDENT
Credential:
Phone: 561-410-5622