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General NPI Number Information
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NPI Number | 1609545003
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Entity Type | Organization
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Legal Business Name | GENESIS TMS & WELLNESS LLC
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Dates
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Enumeration Date | 09/09/2021
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Last Update Date | 07/27/2022
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Provider Practice Location Address
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Address Line | 10337B DEMOCRACY LN
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City | FAIRFAX
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State | VA
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Zip | 22030-2521
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Country | US
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Telephone | 703-955-0915
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Fax |
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Provider Business Mailing Address
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Address Line | 10337 DEMOCRACY LN STE B
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City | FAIRFAX
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State | VA
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Zip | 22030-2551
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Country | US
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Telephone | 703-955-0915
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Fax | 248-243-8804
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. IFEANYI M. OLELE
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Credential | DO
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Telephone | 310-213-9945
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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