=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386464600
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLINICA DE TERAPIA FISICA Y REHABILITACION GENESIS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2024
-----------------------------------------------------
Last Update Date | 10/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CARR #2 KM 100 BO CACAO
-----------------------------------------------------
City | QUEBRADILLAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00678-0980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-895-4633
-----------------------------------------------------
Fax | 787-895-4490
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 980
-----------------------------------------------------
City | QUEBRADILLAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00678-0980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-895-4633
-----------------------------------------------------
Fax | 787-895-4490
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | TERAPISTA FISICO
-----------------------------------------------------
Name | MS. LUZ C BUTLER MOYA
-----------------------------------------------------
Credential | DR
-----------------------------------------------------
Telephone | 787-895-4633
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1800X
-----------------------------------------------------
Taxonomy Name | Corporate Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------