Provider Demographics
NPI:1760015713
Name:GENESIS RECOVERY CENTER, LLC
Entity type:Organization
Organization Name:GENESIS RECOVERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:H
Authorized Official - Last Name:SALTER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LAC, CCS
Authorized Official - Phone:318-251-4659
Mailing Address - Street 1:3138 HIGHWAY 818
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-1370
Mailing Address - Country:US
Mailing Address - Phone:318-278-2793
Mailing Address - Fax:
Practice Address - Street 1:3138 HIGHWAY 818
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-1370
Practice Address - Country:US
Practice Address - Phone:318-278-2793
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1137Medicaid