Provider Demographics
NPI:1912088659
Name:KNOXVILLE RESIDENTIAL, LLC
Entity Type:Organization
Organization Name:KNOXVILLE RESIDENTIAL, LLC
Other - Org Name:KNOXVILLE RESIDENTIAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HEMNESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-250-0670
Mailing Address - Street 1:5095 WINDSOR CIR
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:IA
Mailing Address - Zip Code:50327-0908
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:205 N IOWA ST
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:IA
Practice Address - Zip Code:50138-2833
Practice Address - Country:US
Practice Address - Phone:641-842-4618
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA630299320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0896886Medicaid