=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063869212
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENESIS MEDICAL CENTER CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2016
-----------------------------------------------------
Last Update Date | 05/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7171 SW 24TH ST SUITE 303
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33155-1449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-774-9281
-----------------------------------------------------
Fax | 786-502-8590
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7171 SW 24TH ST SUITE 303
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33155-1449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-774-9281
-----------------------------------------------------
Fax | 786-502-8590
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | PEDRO H PRIETO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-603-4356
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------