Organization
GRANDGEN, LLC
Active
Other names
Devenu Medical Rejuvenation Center
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JON FULCHER (PRESIDENT)
(402) 445-6173
Entity
Organization
Contact information
Practice address
9802 NICHOLAS ST, SUITE 305, OMAHA, NE 68114-2167
(402) 397-2300
(402) 397-2303
Mailing address
9802 NICHOLAS ST, SUITE 305, OMAHA, NE 68114-2167
(402) 397-2300
(402) 397-2303
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
23224
IA
Other
Enumeration date
07/15/2010
Last updated
07/15/2010
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