Provider Demographics
NPI:1003887639
Name:GENESIS DEVELOPMENT
Entity Type:Organization
Organization Name:GENESIS DEVELOPMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-386-3017
Mailing Address - Street 1:PO BOX 438
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:IA
Mailing Address - Zip Code:50129-0438
Mailing Address - Country:US
Mailing Address - Phone:515-386-3017
Mailing Address - Fax:515-386-4642
Practice Address - Street 1:401 W MCKINLEY ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:IA
Practice Address - Zip Code:50129-1421
Practice Address - Country:US
Practice Address - Phone:515-386-3017
Practice Address - Fax:515-386-4642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-31
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251S00000XAgenciesCommunity/Behavioral Health
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0465401Medicaid
IA0465419Medicaid
IA1232363Medicaid
IA0280529Medicaid
IA0465435Medicaid
IA0428656Medicaid
IA0465393Medicaid
IA0243121Medicaid
IA0465534Medicaid
IA0110726Medicaid
IA0232363Medicaid
IA0245829Medicaid
IA0890007Medicaid
IA15-08-003OtherNON POS AGREEMENT NUMBER
IA0245811Medicaid
IA0894865Medicaid
IA1245811Medicaid
IA0290353Medicaid