Provider Demographics
NPI:1467827816
Name:GENETIVITY, LLC THE LAKESIDE VILLAGE
Entity type:Organization
Organization Name:GENETIVITY, LLC THE LAKESIDE VILLAGE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEE
Authorized Official - Middle Name:
Authorized Official - Last Name:ECKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:641-755-3443
Mailing Address - Street 1:2067 HIGHWAY 4
Mailing Address - Street 2:
Mailing Address - City:PANORA
Mailing Address - State:IA
Mailing Address - Zip Code:50216-8601
Mailing Address - Country:US
Mailing Address - Phone:641-755-3443
Mailing Address - Fax:641-755-3980
Practice Address - Street 1:2067 HIGHWAY 4
Practice Address - Street 2:
Practice Address - City:PANORA
Practice Address - State:IA
Practice Address - Zip Code:50216-8601
Practice Address - Country:US
Practice Address - Phone:641-755-3443
Practice Address - Fax:641-755-3980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility