Healthcare Provider Details

I. General information

NPI: 1386389732
Provider Name (Legal Business Name): GENESIS MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2022
Last Update Date: 04/30/2022
Certification Date: 04/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1372 MONTEZUMA CT
LAS VEGAS NV
89119-4513
US

IV. Provider business mailing address

1372 MONTEZUMA CT
LAS VEGAS NV
89119-4513
US

V. Phone/Fax

Practice location:
  • Phone: 702-981-4012
  • Fax:
Mailing address:
  • Phone: 702-981-4012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: YUSLEISY COLLAZO
Title or Position: OWNER
Credential:
Phone: 702-981-4012