Provider Demographics
NPI:1477254894
Name:GENESIS REIGN SUPPORT SERVICES LLC
Entity Type:Organization
Organization Name:GENESIS REIGN SUPPORT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:DWAIN
Authorized Official - Last Name:JACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-926-3696
Mailing Address - Street 1:6406 BAREBACK TER
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23234-4195
Mailing Address - Country:US
Mailing Address - Phone:804-926-3696
Mailing Address - Fax:
Practice Address - Street 1:6406 BAREBACK TER
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23234-4195
Practice Address - Country:US
Practice Address - Phone:804-926-3696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-13
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Single Specialty
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty