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? | Code | Type | Classification | Specialization |
|---|---|---|---|---|
| Yes | 320900000X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities | |
| No | 251C00000X | Agencies | Day Training, Developmentally Disabled Services | |
| No | 320600000X | Residential Treatment Facilities | Residential Treatment Facility, Intellectual and/or Developmental Disabilities | |
| No | 320800000X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | |
| No | 311ZA0620X | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home |
| No | 3104A0630X | Nursing & Custodial Care Facilities | Assisted Living Facility | Assisted Living, Behavioral Disturbances |
| No | 3104A0625X | Nursing & Custodial Care Facilities | Assisted Living Facility | Assisted Living, Mental Illness |
| No | 251S00000X | Agencies | Community/Behavioral Health |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| IA | 0465401 | Medicaid | |
| IA | 0465419 | Medicaid | |
| IA | 1232363 | Medicaid | |
| IA | 0280529 | Medicaid | |
| IA | 0465435 | Medicaid | |
| IA | 0428656 | Medicaid | |
| IA | 0465393 | Medicaid | |
| IA | 0243121 | Medicaid | |
| IA | 0465534 | Medicaid | |
| IA | 0110726 | Medicaid | |
| IA | 0232363 | Medicaid | |
| IA | 0245829 | Medicaid | |
| IA | 0890007 | Medicaid | |
| IA | 15-08-003 | Other | NON POS AGREEMENT NUMBER |
| IA | 0245811 | Medicaid | |
| IA | 0894865 | Medicaid | |
| IA | 1245811 | Medicaid | |
| IA | 0290353 | Medicaid |
