Healthcare Provider Details

I. General information

NPI: 1548520356
Provider Name (Legal Business Name): GENESIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2012
Last Update Date: 05/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15204 W COLONIAL DR
WINTER GARDEN FL
34787-6042
US

IV. Provider business mailing address

15204 W COLONIAL DR
WINTER GARDEN FL
34787-6042
US

V. Phone/Fax

Practice location:
  • Phone: 407-877-2394
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberOTA9873
License Number StateFL

VIII. Authorized Official

Name: LATRICIE E FREEMAN
Title or Position: COTA
Credential:
Phone: 321-945-0713