MEDICARE: GENESIS COMMUNITY WELLNESS LLC

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1720612997
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENESIS COMMUNITY WELLNESS LLC

Provider Business Mailing Address
First Line	:	2720 NW 167TH ST
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33054-6400
Country	:	US
Telephone Number	:	305-318-7391
Fax Number	:

Provider Business Practice Location Address
First Line	:	2720 NW 167TH ST
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33054-6400
Country	:	US
Telephone Number	:	305-318-7391
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	GENESIS ABREU ETTIENNE
Credential	:
Telephone Number	:	305-318-7391

Provider Enumeration Date	:	02/26/2020
Last Update Date	:	02/26/2020

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