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General NPI Number Information
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NPI Number | 1013214014
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Entity Type | Organization
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Legal Business Name | GENESIS MEDICAL GROUP LLC
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Dates
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Enumeration Date | 02/28/2011
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Last Update Date | 08/14/2012
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Provider Practice Location Address
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Address Line | 10802 SE WASHINGTON ST
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City | PORTLAND
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State | OR
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Zip | 97216-3118
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Country | US
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Telephone | 503-699-1911
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Fax | 503-699-1912
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Provider Business Mailing Address
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Address Line | 16679 BOONES FERRY RD STE 215
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City | LAKE OSWEGO
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State | OR
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Zip | 97035-4368
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Country | US
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Telephone | 503-699-1911
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Fax | 503-699-1912
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Authorized Official
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Title or Position | DIRECTOR OF OPERATION
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Name | MR. WYATT JAMES BROWN
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Credential | CPED
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Telephone | 503-699-1911
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number |
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License Number State |
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