Basic Information
| Provider Information | |||||||||
| NPI: | 1962015818 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GENESISCARE LANDMARK IMAGING PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2160 COLONIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339071410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399317342 | ||||||||
| FaxNumber: | 2399317385 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 HARRISON AVE STE 104 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731041819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052725090 | ||||||||
| FaxNumber: | 4052725091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2020 | ||||||||
| LastUpdateDate: | 03/01/2021 | ||||||||
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| AuthorizedOfficialLastName: | TRIPLETT | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4052725090 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 293D00000X | Y | Laboratories | Physiological Laboratory |
No ID Information.