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General NPI Number Information
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NPI Number | 1689835571
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Entity Type | Organization
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Legal Business Name | NEW GENESIS CENTER FOR INTENTIONAL HEALTH & AESTHETICS
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Dates
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Enumeration Date | 06/23/2008
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Last Update Date | 06/23/2008
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Provider Practice Location Address
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Address Line | 556 HALL RD
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City | THOMASVILLE
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State | GA
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Zip | 31757-8105
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Country | US
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Telephone | 229-228-9050
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Fax | 229-228-9056
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Provider Business Mailing Address
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Address Line | 556 HALL RD
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City | THOMASVILLE
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State | GA
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Zip | 31757-8105
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Country | US
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Telephone | 229-228-9050
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Fax | 229-228-9056
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Authorized Official
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Title or Position | CO-OWNER
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Name | PATRICE BULLOCK
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Credential | FNP-C
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Telephone | 229-228-9050
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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