=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366844524
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENESIS CASE MANAGEMENT SERVICES, CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2014
-----------------------------------------------------
Last Update Date | 09/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8181 NW 36TH ST SUITE 24
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33166-6671
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-639-9639
-----------------------------------------------------
Fax | 305-381-0735
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8181 NW 36TH ST SUITE 24
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33166-6671
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-639-9639
-----------------------------------------------------
Fax | 305-381-0735
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JORGE BRACERAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-639-9639
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------