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General NPI Number Information
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NPI Number | 1750741740
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Entity Type | Organization
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Legal Business Name | GENESIS WOUND CARE OF LAS VEGAS, LLC
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Dates
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Enumeration Date | 03/03/2016
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Last Update Date | 03/03/2016
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Provider Practice Location Address
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Address Line | 2410 FIRE MESA ST SUITE 160
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City | LAS VEGAS
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State | NV
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Zip | 89128-9016
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Country | US
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Telephone | 702-518-1534
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Fax | 702-931-3944
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Provider Business Mailing Address
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Address Line | 575 N ROUTE 73 SUITE A6
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City | WEST BERLIN
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State | NJ
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Zip | 08091-9289
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Country | US
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Telephone | 856-335-5025
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Fax | 856-213-9269
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Authorized Official
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Title or Position | PRINICIPAL
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Name | JAMES THOMAS O'DARE III
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Credential |
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Telephone | 856-335-5025
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 332BX2000X
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Taxonomy Name | Oxygen Equipment & Supplies (DME)
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 2083P0011X
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Taxonomy Name | Undersea and Hyperbaric Medicine (Preventive Medicine) Physician
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License Number |
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License Number State |
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