Provider Demographics
NPI:1306516919
Name:GENESIS WOUND CARE CENTER LLC
Entity type:Organization
Organization Name:GENESIS WOUND CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAYELIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ALONSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-603-8410
Mailing Address - Street 1:4995 NW 72ND AVE STE 406
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33166-5643
Mailing Address - Country:US
Mailing Address - Phone:305-603-8410
Mailing Address - Fax:786-431-5976
Practice Address - Street 1:4995 NW 72ND AVE STE 406
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33166-5643
Practice Address - Country:US
Practice Address - Phone:305-603-8410
Practice Address - Fax:786-431-5976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-15
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center