MEDICARE: GENESIS WOUND CARE SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0025SA	OTHER	TX	BLUE CROSS BLUE SHIELD OF TX
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730334103
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENESIS WOUND CARE SERVICES

Provider Business Mailing Address
First Line	:	5201 WINTERBERRRY COURT
Second Line	:
City	:	FT. WORTH
State	:	TX
Zip	:	76244
Country	:	US
Telephone Number	:	817-875-0224
Fax Number	:	817-431-5296

Provider Business Practice Location Address
First Line	:	5201 WINTERBERRY CT.
Second Line	:
City	:	FT.WORTH
State	:	TX
Zip	:	76244
Country	:	US
Telephone Number	:	817-875-0224
Fax Number	:	817-431-5296

Authorized Official
Title or Position	:	BUSINESS MGR.
Name	:	MR. FREDERICK D ACUNA
Credential	:
Telephone Number	:	817-875-0224

Provider Enumeration Date	:	11/26/2008
Last Update Date	:	12/12/2011

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