MEDICARE: GENESIS ADILENE VILLA

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	106S00000X	Behavior Technician	RBT-22-247856	CA

General Provider Information

NPI Number	:	1710706445
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GENESIS ADILENE VILLA

Provider Business Mailing Address
First Line	:	2109 N MICHAEL WAY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-3173
Country	:	US
Telephone Number	:	818-391-2741
Fax Number	:

Provider Business Practice Location Address
First Line	:	2109 N MICHAEL WAY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-3173
Country	:	US
Telephone Number	:	818-391-2741
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/09/2024
Last Update Date	:	10/09/2024

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Directions to “ GENESIS ADILENE VILLA ” Practice Location

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