Organization
GENESIS REIGN SUPPORT SERVICES LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. DERRICK DWAIN JACK (OWNER)
(804) 926-3696
Entity
Organization
Contact information
Practice address
6406 BAREBACK TER, NORTH CHESTERFIELD, VA 23234-4195
(804) 926-3696
Mailing address
6406 BAREBACK TER, NORTH CHESTERFIELD, VA 23234-4195
(804) 926-3696
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
—
—
Other
Enumeration date
03/13/2023
Last updated
10/11/2023
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