Provider Demographics
NPI:1235472671
Name:GENESTEM
Entity Type:Organization
Organization Name:GENESTEM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DELUCA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-537-2603
Mailing Address - Street 1:1022 JEFFERY ST
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-4183
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4101 NW 4TH ST
Practice Address - Street 2:SUITE 211
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-2850
Practice Address - Country:US
Practice Address - Phone:561-537-2603
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZME102199261QG0250X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QG0250XAmbulatory Health Care FacilitiesClinic/CenterGenetics