Healthcare Provider Details

I. General information

NPI: 1902580293
Provider Name (Legal Business Name): GENESISCARE USA OF FLORIDA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2023
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 CENTER RD STE B
VENICE FL
34285-5565
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 941-492-6227
  • Fax: 941-492-6335
Mailing address:
  • Phone: 238-931-7342
  • Fax: 238-931-7385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

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