Provider Demographics
NPI:1528507068
Name:GENESIS LIFE LLC
Entity type:Organization
Organization Name:GENESIS LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KELVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-936-9197
Mailing Address - Street 1:PO BOX 1967
Mailing Address - Street 2:
Mailing Address - City:IOWA
Mailing Address - State:LA
Mailing Address - Zip Code:70647-1967
Mailing Address - Country:US
Mailing Address - Phone:337-936-9197
Mailing Address - Fax:337-588-4179
Practice Address - Street 1:21089 SOUTH FRONTAGE ROAD
Practice Address - Street 2:
Practice Address - City:LACASSINE
Practice Address - State:LA
Practice Address - Zip Code:70650
Practice Address - Country:US
Practice Address - Phone:337-936-9197
Practice Address - Fax:337-588-4179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-16
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA276400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit