Organization
GENESIS MEDICAL GROUP LLC
Active
Organization
GENESIS MEDICAL GROUP LLC
Active
Parent organization
GENESIS MEDICAL GROUP, LLC
Organization subpart
Yes
Provider details
NPI number
Legal business name
GENESIS MEDICAL GROUP, LLC
Authorized official
MR. WYATT JAMES BROWN CPED (DIRECTOR OF OPERATION)
(503) 699-1911
Entity
Organization
Contact information
Practice address
10802 SE WASHINGTON ST, PORTLAND, OR 97216-3118
(503) 699-1911
(503) 699-1912
Mailing address
16679 BOONES FERRY RD STE 215, LAKE OSWEGO, OR 97035-4368
(503) 699-1911
(503) 699-1912
Taxonomy
Speciality
Code
Description
License number
State
335E00000X
Prosthetic/Orthotic Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
500608071
—
OR
Enumeration date
02/28/2011
Last updated
08/14/2012
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