Provider Demographics
NPI:1457768814
Name:GENESIS AND LIGHT CENTER
Entity Type:Organization
Organization Name:GENESIS AND LIGHT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-362-6736
Mailing Address - Street 1:4914 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-4046
Mailing Address - Country:US
Mailing Address - Phone:601-362-6736
Mailing Address - Fax:601-362-6737
Practice Address - Street 1:4914 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-4046
Practice Address - Country:US
Practice Address - Phone:601-362-6736
Practice Address - Fax:601-362-6737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-17
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS25C4PAS-5598251V00000X
261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No251V00000XAgenciesVoluntary or Charitable