Healthcare Provider Details

I. General information

NPI: 1336470616
Provider Name (Legal Business Name): GENESIS HEALTH AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2010
Last Update Date: 08/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8211 W STATE ROUTE 66
NEWBURGH IN
47630-2534
US

IV. Provider business mailing address

8211 W STATE ROUTE 66
NEWBURGH IN
47630-2534
US

V. Phone/Fax

Practice location:
  • Phone: 812-858-1005
  • Fax: 812-858-1001
Mailing address:
  • Phone: 812-858-1005
  • Fax: 812-858-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number08002011A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number08002011A
License Number StateIN

VIII. Authorized Official

Name: DR. SHAUN P TYMCHAK
Title or Position: DIRECTOR
Credential: DC
Phone: 812-858-1005