Healthcare Provider Details

I. General information

NPI: 1114202611
Provider Name (Legal Business Name): GENESIS II AGE MANAGEMENT, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2011
Last Update Date: 10/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 W. MAYFIELD ROAD SUITE 416
ARLINGTON TX
76014-2085
US

IV. Provider business mailing address

515 W. MAYFIELD ROAD SUITE 416
ARLINGTON TX
76014-2085
US

V. Phone/Fax

Practice location:
  • Phone: 817-419-8748
  • Fax: 817-419-8788
Mailing address:
  • Phone: 817-419-8748
  • Fax: 817-419-8788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberE1000
License Number StateTX

VIII. Authorized Official

Name: DR. RONALD STEVEN KLINE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 817-419-8748