=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326510868
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENETESIS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2018
-----------------------------------------------------
Last Update Date | 12/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5412 COURSEVIEW DR STE 150
-----------------------------------------------------
City | MASON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45040-2483
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-767-7627
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5412 COURSEVIEW DR STE 150
-----------------------------------------------------
City | MASON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45040-2483
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-767-7627
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP, BUSINESS DEVELOPMENT
-----------------------------------------------------
Name | JEFFREY BUSH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 303-667-9788
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------