Healthcare Provider Details

I. General information

NPI: 1083676480
Provider Name (Legal Business Name): GENESIS MEDICAL PRACTICE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 12/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 CALLE MIGUEL CASILLAS
HUMACAO PR
00791-3638
US

IV. Provider business mailing address

PO BOX 890 MCS 549
HUMACAO PR
00792-0890
US

V. Phone/Fax

Practice location:
  • Phone: 787-285-2415
  • Fax: 787-285-4590
Mailing address:
  • Phone: 787-285-2415
  • Fax: 787-285-4590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State

VIII. Authorized Official

Name: MISS BRENDA LEE VELAZQUEZ PEREZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 787-285-2415