Healthcare Provider Details

I. General information

NPI: 1093753790
Provider Name (Legal Business Name): GENESIS AMBULATORY MEDICAL CARE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13780 SW 26TH ST SUITE 205
MIAMI FL
33175-6302
US

IV. Provider business mailing address

13780 SW 26TH ST SUITE 205
MIAMI FL
33175-6302
US

V. Phone/Fax

Practice location:
  • Phone: 305-227-8878
  • Fax:
Mailing address:
  • Phone: 305-227-8878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. COLOMBIA PATINO
Title or Position: PRESIDENT
Credential:
Phone: 305-227-8878