Provider Demographics
NPI:1265829303
Name:GENESIS SURGICAL ASSISTING LLC
Entity Type:Organization
Organization Name:GENESIS SURGICAL ASSISTING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:CURTIS
Authorized Official - Suffix:
Authorized Official - Credentials:CSFA
Authorized Official - Phone:208-866-8277
Mailing Address - Street 1:348 W BLOOMINGTON DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6942
Mailing Address - Country:US
Mailing Address - Phone:208-866-8277
Mailing Address - Fax:
Practice Address - Street 1:348 W BLOOMINGTON DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6942
Practice Address - Country:US
Practice Address - Phone:208-866-8277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-15
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID116257246ZC0007X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Multi-Specialty