Provider Demographics
NPI:1982101358
Name:GENESIS VIDA HEALTH SERVICES
Entity Type:Organization
Organization Name:GENESIS VIDA HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENYATTA
Authorized Official - Middle Name:
Authorized Official - Last Name:FLETCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-472-6231
Mailing Address - Street 1:4412 EL PARQUE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-3502
Mailing Address - Country:US
Mailing Address - Phone:702-472-6231
Mailing Address - Fax:
Practice Address - Street 1:6075 SILKEN SADDLE ST
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-6854
Practice Address - Country:US
Practice Address - Phone:702-472-6231
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-11
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health