Healthcare Provider Details

I. General information

NPI: 1750741740
Provider Name (Legal Business Name): GENESIS WOUND CARE OF LAS VEGAS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2016
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2410 FIRE MESA ST SUITE 160
LAS VEGAS NV
89128-9016
US

IV. Provider business mailing address

575 N ROUTE 73 SUITE A6
WEST BERLIN NJ
08091-9289
US

V. Phone/Fax

Practice location:
  • Phone: 702-518-1534
  • Fax: 702-931-3944
Mailing address:
  • Phone: 856-335-5025
  • Fax: 856-213-9269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES THOMAS O'DARE III
Title or Position: PRINICIPAL
Credential:
Phone: 856-335-5025