Healthcare Provider Details

I. General information

NPI: 1851165716
Provider Name (Legal Business Name): GENESIS VILLALTA CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2023
Last Update Date: 04/24/2025
Certification Date: 04/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3605 VISTA WAY STE 258
OCEANSIDE CA
92056-4565
US

IV. Provider business mailing address

3605 VISTA WAY STE 258
OCEANSIDE CA
92056-4565
US

V. Phone/Fax

Practice location:
  • Phone: 760-758-1480
  • Fax:
Mailing address:
  • Phone: 760-758-1480
  • Fax: 760-435-9472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: