Provider Demographics
NPI:1851166813
Name:GENESIS WELLNESS CENTER PLLC
Entity Type:Organization
Organization Name:GENESIS WELLNESS CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:C
Authorized Official - Last Name:GAINES
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:502-644-9162
Mailing Address - Street 1:4507 MEADOWLARK MANOR LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-2702
Mailing Address - Country:US
Mailing Address - Phone:502-644-9162
Mailing Address - Fax:502-390-0330
Practice Address - Street 1:3000 S 5TH ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40208-1312
Practice Address - Country:US
Practice Address - Phone:502-644-9162
Practice Address - Fax:502-390-0330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty