MEDICARE: GENESIS VIDA HEALTH SERVICES

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1982101358
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENESIS VIDA HEALTH SERVICES

Provider Business Mailing Address
First Line	:	4412 EL PARQUE AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-3502
Country	:	US
Telephone Number	:	702-472-6231
Fax Number	:

Provider Business Practice Location Address
First Line	:	6075 SILKEN SADDLE ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-6854
Country	:	US
Telephone Number	:	702-472-6231
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KENYATTA FLETCHER
Credential	:
Telephone Number	:	702-472-6231

Provider Enumeration Date	:	04/11/2018
Last Update Date	:	10/09/2020

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