Provider Demographics
NPI:1679126445
Name:BLUE GENESIS HOLDINGS LLC
Entity Type:Organization
Organization Name:BLUE GENESIS HOLDINGS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MAX
Authorized Official - Middle Name:
Authorized Official - Last Name:WILTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-435-9574
Mailing Address - Street 1:2013 WEATHERBY WAY CT
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-7769
Mailing Address - Country:US
Mailing Address - Phone:470-435-9574
Mailing Address - Fax:
Practice Address - Street 1:2013 WEATHERBY WAY CT
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-7769
Practice Address - Country:US
Practice Address - Phone:470-435-9574
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies