Provider Demographics
NPI:1326351651
Name:GRANDGEN, LLC
Entity Type:Organization
Organization Name:GRANDGEN, LLC
Other - Org Name:DEVENU MEDICAL REJUVENATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:FULCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-445-6173
Mailing Address - Street 1:9802 NICHOLAS ST
Mailing Address - Street 2:SUITE 305
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-2167
Mailing Address - Country:US
Mailing Address - Phone:402-397-2300
Mailing Address - Fax:402-397-2303
Practice Address - Street 1:9802 NICHOLAS ST
Practice Address - Street 2:SUITE 305
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2167
Practice Address - Country:US
Practice Address - Phone:402-397-2300
Practice Address - Fax:402-397-2303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-15
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA23224174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty