Provider Demographics
NPI:1356314801
Name:DEVELOPMENTAL RESOURCES, INC.
Entity Type:Organization
Organization Name:DEVELOPMENTAL RESOURCES, INC.
Other - Org Name:KRYSILIS, INC.-INDIAN AVENUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:V
Authorized Official - Last Name:ABERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-585-5450
Mailing Address - Street 1:905 HIGHWAY 69 S
Mailing Address - Street 2:
Mailing Address - City:FOREST CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50436-2100
Mailing Address - Country:US
Mailing Address - Phone:641-585-3050
Mailing Address - Fax:641-585-3939
Practice Address - Street 1:138 INDIAN AVE
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:IA
Practice Address - Zip Code:50436-2321
Practice Address - Country:US
Practice Address - Phone:641-585-5502
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA950057320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0880690Medicaid
IAIA00552OtherSUBMITTER ID