Healthcare Provider Details

I. General information

NPI: 1295513299
Provider Name (Legal Business Name): GENEXT LIFE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2023
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 SANDY AVE
CHARLOTTE NC
28213-5659
US

IV. Provider business mailing address

1235 EAST BLVD STE E
CHARLOTTE NC
28203-5876
US

V. Phone/Fax

Practice location:
  • Phone: 980-705-1190
  • Fax:
Mailing address:
  • Phone: 980-705-1190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: ECAROH JACKSON
Title or Position: MANAGING MEMBER
Credential:
Phone: 404-642-4493