Organization
GENESIS FAMILY PRACTICE, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JAY CROSSETTE CHANMUGAM D.O. (OWNER)
(386) 878-4137
Entity
Organization
Contact information
Practice address
1133 SAXON BLVD, ORANGE CITY, FL 32763-8425
(386) 228-9700
Mailing address
1133 SAXON BLVD, ORANGE CITY, FL 32763-8425
(386) 878-4137
(386) 878-4293
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
OS8600
FL
291U00000X
Clinical Medical Laboratory
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
008488100
—
FL
Enumeration date
09/27/2012
Last updated
11/28/2022
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