MEDICARE: GENESIS WELLNESS SUPPORT CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician
2	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1235993155
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENESIS WELLNESS SUPPORT CORP

Provider Business Mailing Address
First Line	:	9333 SW 227TH ST UNIT 1
Second Line	:
City	:	CUTLER BAY
State	:	FL
Zip	:	33190-1947
Country	:	US
Telephone Number	:	786-740-0516
Fax Number	:	786-221-2834

Provider Business Practice Location Address
First Line	:	10700 CARIBBEAN BLVD STE 214
Second Line	:
City	:	CUTLER BAY
State	:	FL
Zip	:	33189-1233
Country	:	US
Telephone Number	:	786-207-1151
Fax Number	:	786-221-2834

Authorized Official
Title or Position	:	OWNER
Name	:	YISCEL MARIA M PASCUAL BERMUDEZ
Credential	:	CBHCMS
Telephone Number	:	786-207-1151

Provider Enumeration Date	:	02/12/2024
Last Update Date	:	05/18/2026

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