Healthcare Provider Details

I. General information

NPI: 1427303494
Provider Name (Legal Business Name): GENESIS SERVICE DOGS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2012
Last Update Date: 07/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 W BROADWAY AVE
MERIDIAN ID
83642-2404
US

IV. Provider business mailing address

621 W BROADWAY AVE
MERIDIAN ID
83642-2404
US

V. Phone/Fax

Practice location:
  • Phone: 208-761-4884
  • Fax:
Mailing address:
  • Phone: 208-761-4884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MS. DANIELLE STEM
Title or Position: PRESIDENT
Credential:
Phone: 208-761-4884