Healthcare Provider Details

I. General information

NPI: 1639428337
Provider Name (Legal Business Name): THE GENESIS RENEW M & A, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2012
Last Update Date: 09/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1059 GRANADA BLVD
NAPLES FL
34103-2514
US

IV. Provider business mailing address

1059 GRANADA BLVD
NAPLES FL
34103-2514
US

V. Phone/Fax

Practice location:
  • Phone: 239-207-0853
  • Fax: 239-435-1651
Mailing address:
  • Phone: 239-207-0853
  • Fax: 239-435-1651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: MRS. ANAYS A RICARDO
Title or Position: PRESIDENT
Credential: ME
Phone: 239-207-0853