Provider Demographics
NPI:1336642545
Name:GENESISCARE USA OF FLORIDA LLC
Entity Type:Organization
Organization Name:GENESISCARE USA OF FLORIDA LLC
Other - Org Name:BLACKWELL BREAST SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-931-7275
Mailing Address - Street 1:2270 COLONIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:7451 GLADIOLUS DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-5193
Practice Address - Country:US
Practice Address - Phone:239-931-7212
Practice Address - Fax:239-931-7385
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESISCARE USA INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-14
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty