Provider Demographics
NPI:1851548218
Name:GENESIS MEDICAL LASER CENTER, LLC
Entity Type:Organization
Organization Name:GENESIS MEDICAL LASER CENTER, LLC
Other - Org Name:GENESIS MEDICAL LASER CTR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:STEMM
Authorized Official - Suffix:
Authorized Official - Credentials:CLT
Authorized Official - Phone:270-842-6096
Mailing Address - Street 1:1711 DESTINY LN
Mailing Address - Street 2:SUITE 107
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-1066
Mailing Address - Country:US
Mailing Address - Phone:270-842-6096
Mailing Address - Fax:270-842-6097
Practice Address - Street 1:1711 DESTINY LN
Practice Address - Street 2:SUITE 107
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-1066
Practice Address - Country:US
Practice Address - Phone:270-842-6096
Practice Address - Fax:270-842-6097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain