MEDICARE: GENESIS MEDICAL CLINIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician
2	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1386389732
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENESIS MEDICAL CLINIC LLC

Provider Business Mailing Address
First Line	:	1372 MONTEZUMA CT
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-4513
Country	:	US
Telephone Number	:	702-981-4012
Fax Number	:

Provider Business Practice Location Address
First Line	:	1372 MONTEZUMA CT
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-4513
Country	:	US
Telephone Number	:	702-981-4012
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	YUSLEISY COLLAZO
Credential	:
Telephone Number	:	702-981-4012

Provider Enumeration Date	:	04/30/2022
Last Update Date	:	04/30/2022

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