Healthcare Provider Details

I. General information

NPI: 1821285826
Provider Name (Legal Business Name): GENESISCARE USA OF FLORIDA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2007
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 N FLAMINGO RD STE 319
PEMBROKE PINES FL
33028-1011
US

IV. Provider business mailing address

1419 SE 8TH TER STE 200
CAPE CORAL FL
33990-3213
US

V. Phone/Fax

Practice location:
  • Phone: 954-987-3010
  • Fax: 954-987-0032
Mailing address:
  • Phone: 239-931-7342
  • Fax: 239-931-7385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: IAN WONG
Title or Position: CFO
Credential:
Phone: 303-249-7486