Provider Demographics
NPI:1518030337
Name:GENESIS HOSPICE CARE
Entity Type:Organization
Organization Name:GENESIS HOSPICE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARLINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANDON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:662-846-0922
Mailing Address - Street 1:6341 HWY 51 NORTH
Mailing Address - Street 2:SUITE 6
Mailing Address - City:HORN LAKE
Mailing Address - State:MS
Mailing Address - Zip Code:38937
Mailing Address - Country:US
Mailing Address - Phone:662-393-3414
Mailing Address - Fax:662-393-3474
Practice Address - Street 1:201 WEST SUNFLOWER ROAD
Practice Address - Street 2:POB 1888
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732
Practice Address - Country:US
Practice Address - Phone:662-846-0922
Practice Address - Fax:662-846-0833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04788594Medicaid
MS04788594Medicaid