Provider Demographics
NPI:1194048884
Name:GENESIS CLINICA DE LA MUJER INC
Entity type:Organization
Organization Name:GENESIS CLINICA DE LA MUJER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:ELENA
Authorized Official - Last Name:HEREDIA
Authorized Official - Suffix:
Authorized Official - Credentials:MSN
Authorized Official - Phone:408-258-3724
Mailing Address - Street 1:244 N JACKSON AVE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-1604
Mailing Address - Country:US
Mailing Address - Phone:408-258-3724
Mailing Address - Fax:408-258-3736
Practice Address - Street 1:244 N JACKSON AVE
Practice Address - Street 2:SUITE 209
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1604
Practice Address - Country:US
Practice Address - Phone:408-258-3724
Practice Address - Fax:408-258-3736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-09
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75190207R00000X
CAG81814207V00000X
CANP9507363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & GynecologyGroup - Multi-Specialty