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General NPI Number Information
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NPI Number | 1255824777
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Entity Type | Organization
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Legal Business Name | GENESIS WELLNESS GROUP LLC
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Dates
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Enumeration Date | 06/09/2018
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Last Update Date | 06/09/2018
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Provider Practice Location Address
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Address Line | 65 BROADWAY STE 1602
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City | NEW YORK
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State | NY
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Zip | 10006-2576
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Country | US
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Telephone | 718-316-1280
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Fax |
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Provider Business Mailing Address
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Address Line | 3450 WAYNE AVE APT 14A
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City | BRONX
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State | NY
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Zip | 10467-2515
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Country | US
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Telephone | 171-831-6128
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Fax |
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Authorized Official
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Title or Position | CHIEF WELLNESS COORDINATOR
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Name | JERRY GENESIS
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Credential |
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Telephone | 718-316-1280
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 038095-1
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License Number State | NY
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