Healthcare Provider Details

I. General information

NPI: 1023369204
Provider Name (Legal Business Name): GENESIS FAMILY PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2012
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date: 04/09/2018
Reactivation Date: 04/17/2018

III. Provider practice location address

1133 SAXON BLVD
ORANGE CITY FL
32763-8425
US

IV. Provider business mailing address

1133 SAXON BLVD
ORANGE CITY FL
32763-8425
US

V. Phone/Fax

Practice location:
  • Phone: 386-228-9700
  • Fax:
Mailing address:
  • Phone: 386-878-4137
  • Fax: 386-878-4293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS8600
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: DR. JAY CROSSETTE CHANMUGAM
Title or Position: OWNER
Credential: D.O.
Phone: 386-878-4137