Provider Demographics
NPI:1871779470
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:L
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:2008-01-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health