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General NPI Number Information
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NPI Number | 1235472671
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Entity Type | Organization
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Legal Business Name | GENESTEM
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Dates
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Enumeration Date | 04/04/2013
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Last Update Date | 04/04/2013
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Provider Practice Location Address
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Address Line | 4101 NW 4TH ST SUITE 211
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City | PLANTATION
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State | FL
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Zip | 33317-2850
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Country | US
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Telephone | 561-537-2603
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Fax |
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Provider Business Mailing Address
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Address Line | 1022 JEFFERY ST
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City | BOCA RATON
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State | FL
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Zip | 33487-4183
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CMO
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Name | JOHN DELUCA
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Credential | M.D.
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Telephone | 561-537-2603
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QG0250X
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Taxonomy Name | Genetics Clinic/Center
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License Number | ME102199
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License Number State | ZZ
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