Provider Demographics
NPI:1295513299
Name:GENEXT LIFE LLC
Entity type:Organization
Organization Name:GENEXT LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ECAROH
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-642-4493
Mailing Address - Street 1:1235 EAST BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5876
Mailing Address - Country:US
Mailing Address - Phone:980-705-1190
Mailing Address - Fax:
Practice Address - Street 1:113 VAQUARO DR
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-0236
Practice Address - Country:US
Practice Address - Phone:980-705-1190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-20
Last Update Date:2024-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No251S00000XAgenciesCommunity/Behavioral Health
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children