Provider Demographics
NPI:1730334103
Name:GENESIS WOUND CARE SERVICES
Entity type:Organization
Organization Name:GENESIS WOUND CARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MGR.
Authorized Official - Prefix:MR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:D
Authorized Official - Last Name:ACUNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-875-0224
Mailing Address - Street 1:5201 WINTERBERRRY COURT
Mailing Address - Street 2:
Mailing Address - City:FT. WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244
Mailing Address - Country:US
Mailing Address - Phone:817-875-0224
Mailing Address - Fax:817-431-5296
Practice Address - Street 1:5201 WINTERBERRY CT.
Practice Address - Street 2:
Practice Address - City:FT.WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244
Practice Address - Country:US
Practice Address - Phone:817-875-0224
Practice Address - Fax:817-431-5296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-26
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0025SAOtherBLUE CROSS BLUE SHIELD OF TX
TX202419201Medicaid
TX202419201Medicaid