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General NPI Number Information
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NPI Number | 1528507068
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Entity Type | Organization
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Legal Business Name | GENESIS LIFE LLC
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Dates
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Enumeration Date | 02/16/2017
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Last Update Date | 02/16/2017
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Provider Practice Location Address
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Address Line | 21089 SOUTH FRONTAGE ROAD
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City | LACASSINE
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State | LA
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Zip | 70650
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Country | US
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Telephone | 337-936-9197
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Fax | 337-588-4179
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Provider Business Mailing Address
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Address Line | PO BOX 1967
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City | IOWA
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State | LA
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Zip | 70647-1967
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Country | US
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Telephone | 337-936-9197
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Fax | 337-588-4179
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. KELVIN M SMITH
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Credential |
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Telephone | 337-936-9197
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 276400000X
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Taxonomy Name | Substance Use Disorder Rehabilitation Hospital Unit
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License Number |
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License Number State | LA
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