Provider Demographics
NPI:1447521968
Name:VILLANUEVA, GENESIS B (PT)
Entity type:Individual
Prefix:
First Name:GENESIS
Middle Name:B
Last Name:VILLANUEVA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40767
Mailing Address - Street 2:CREDENTIALING DEPARTMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32203-0767
Mailing Address - Country:US
Mailing Address - Phone:904-376-3707
Mailing Address - Fax:904-391-5807
Practice Address - Street 1:12961 N MAIN ST STE 201&202
Practice Address - Street 2:CREDENTIALING DEPARTMENT
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-2769
Practice Address - Country:US
Practice Address - Phone:904-757-2474
Practice Address - Fax:904-757-5541
Is Sole Proprietor?:No
Enumeration Date:2012-01-13
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT27082225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01016039OtherRR MEDICARE
FLP01016039OtherRR MEDICARE