Provider Demographics
NPI:1104547322
Name:GENESIS BRAIN INSTITUTE LLC
Entity type:Organization
Organization Name:GENESIS BRAIN INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:D
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-784-8600
Mailing Address - Street 1:3030 N ROCKY POINT DR W STE 665
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-5906
Mailing Address - Country:US
Mailing Address - Phone:727-784-8600
Mailing Address - Fax:
Practice Address - Street 1:3030 N ROCKY POINT DR W STE 665
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-5906
Practice Address - Country:US
Practice Address - Phone:727-784-8600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty