=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790727477
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENESYS DURABLE MEDICAL EQUIPMENT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2006
-----------------------------------------------------
Last Update Date | 06/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 960 CESERY BLVD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32211-5608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-745-5121
-----------------------------------------------------
Fax | 904-745-5339
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 960 CESERY BLVD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32211-5608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-745-5421
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER /PRESIDENT
-----------------------------------------------------
Name | MR. SONNY U UKPONG SR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-745-5121
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 2264
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------