=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679455083
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MODERN HEALTHCARE FAMILY HEALTH NP PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2025
-----------------------------------------------------
Last Update Date | 07/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5800 ARLINGTON AVE APT 10W
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10471-1413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-405-5490
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5800 ARLINGTON AVE APT 10W
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10471-1413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-405-5490
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GENESIS GRULLON
-----------------------------------------------------
Credential | NURSE PRACTITIONER
-----------------------------------------------------
Telephone | 917-405-5490
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251J00000X
-----------------------------------------------------
Taxonomy Name | Nursing Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------