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General NPI Number Information
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NPI Number | 1457768814
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Entity Type | Organization
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Legal Business Name | GENESIS AND LIGHT CENTER
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Dates
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Enumeration Date | 07/17/2014
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Last Update Date | 03/17/2023
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Provider Practice Location Address
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Address Line | 4914 N STATE ST
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City | JACKSON
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State | MS
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Zip | 39206-4046
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Country | US
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Telephone | 601-362-6736
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Fax | 601-362-6737
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Provider Business Mailing Address
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Address Line | 4914 N STATE ST
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City | JACKSON
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State | MS
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Zip | 39206-4046
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Country | US
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Telephone | 601-362-6736
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Fax | 601-362-6737
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | ALBERT WILSON
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Credential |
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Telephone | 601-362-6736
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251V00000X
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Taxonomy Name | Voluntary or Charitable Agency
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License Number | 25C4PAS-5598
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 261QA0600X
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Taxonomy Name | Adult Day Care Clinic/Center
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License Number |
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License Number State |
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