Healthcare Provider Details

I. General information

NPI: 1457485344
Provider Name (Legal Business Name): GENESIS BODYWORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 02/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4075 A1A S SUITE 105
ST AUGUSTINE FL
32080-6773
US

IV. Provider business mailing address

4075 A1A S SUITE 105
ST AUGUSTINE FL
32080-6773
US

V. Phone/Fax

Practice location:
  • Phone: 904-471-2999
  • Fax: 904-471-1722
Mailing address:
  • Phone: 904-471-2999
  • Fax: 904-471-1722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. TAMMY LOUISE LAGASSE
Title or Position: OWNER
Credential: P.T.A., L.M.T.
Phone: 904-471-2999