Provider Demographics
NPI:1750741740
Name:GENESIS WOUND CARE OF LAS VEGAS, LLC
Entity type:Organization
Organization Name:GENESIS WOUND CARE OF LAS VEGAS, 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 1:2410 FIRE MESA ST
Practice Address - Street 2:SUITE 160
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-9016
Practice Address - Country:US
Practice Address - Phone:702-518-1534
Practice Address - Fax:702-931-3944
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESIS WOUNDCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric MedicineGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies