Provider Demographics
NPI:1467815472
Name:GENESIS WOUND CARE OF POOLER, LLC
Entity Type:Organization
Organization Name:GENESIS WOUND CARE OF POOLER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINICIPAL
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:O'DARE
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:856-335-5025
Mailing Address - Street 1:575 N ROUTE 73
Mailing Address - Street 2:SUITE A6
Mailing Address - City:WEST BERLIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08091-9289
Mailing Address - Country:US
Mailing Address - Phone:856-335-5025
Mailing Address - Fax:856-213-9269
Practice Address - Street 1:1000 TOWNE CENTER BLVD
Practice Address - Street 2:BUILDING 400
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-4052
Practice Address - Country:US
Practice Address - Phone:912-662-0223
Practice Address - Fax:912-662-0224
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESIS WOUNDCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-03-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & SuppliesGroup - Multi-Specialty