Provider Demographics
NPI:1629437090
Name:GENESIS5 LLC
Entity Type:Organization
Organization Name:GENESIS5 LLC
Other - Org Name:5 STAR MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ALVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PONCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-324-2612
Mailing Address - Street 1:7066 VILLAGE PKWY
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:CA
Mailing Address - Zip Code:94568-2408
Mailing Address - Country:US
Mailing Address - Phone:925-318-5555
Mailing Address - Fax:
Practice Address - Street 1:7066 VILLAGE PARKWAY
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:CA
Practice Address - Zip Code:94568
Practice Address - Country:US
Practice Address - Phone:925-324-2612
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-15
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA474684618332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies