Provider Demographics
NPI:1790038677
Name:GENESIS SENIOR LIVING, ALEDO
Entity Type:Organization
Organization Name:GENESIS SENIOR LIVING, ALEDO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:P
Authorized Official - Last Name:CROPPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-421-6510
Mailing Address - Street 1:309 NW 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:ALEDO
Mailing Address - State:IL
Mailing Address - Zip Code:61231-1330
Mailing Address - Country:US
Mailing Address - Phone:309-582-5361
Mailing Address - Fax:309-582-5518
Practice Address - Street 1:309 NW 9TH AVE
Practice Address - Street 2:
Practice Address - City:ALEDO
Practice Address - State:IL
Practice Address - Zip Code:61231-1330
Practice Address - Country:US
Practice Address - Phone:309-582-5361
Practice Address - Fax:309-582-5518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-17
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146138Medicare Oscar/Certification
IL=========001Medicaid