Provider Demographics
NPI:1386464600
Name:CLINICA DE TERAPIA FISICA Y REHABILITACION GENESIS LLC
Entity type:Organization
Organization Name:CLINICA DE TERAPIA FISICA Y REHABILITACION GENESIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TERAPISTA FISICO
Authorized Official - Prefix:MS
Authorized Official - First Name:LUZ
Authorized Official - Middle Name:C
Authorized Official - Last Name:BUTLER MOYA
Authorized Official - Suffix:
Authorized Official - Credentials:DR
Authorized Official - Phone:787-895-4633
Mailing Address - Street 1:PO BOX 980
Mailing Address - Street 2:
Mailing Address - City:QUEBRADILLAS
Mailing Address - State:PR
Mailing Address - Zip Code:00678-0980
Mailing Address - Country:US
Mailing Address - Phone:787-895-4633
Mailing Address - Fax:787-895-4490
Practice Address - Street 1:CARR #2 KM 100 BO CACAO
Practice Address - Street 2:
Practice Address - City:QUEBRADILLAS
Practice Address - State:PR
Practice Address - Zip Code:00678-0980
Practice Address - Country:US
Practice Address - Phone:787-895-4633
Practice Address - Fax:787-895-4490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-11
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1609985621Medicaid
PR1346245032Medicaid