Healthcare Provider Details

I. General information

NPI: 1356572358
Provider Name (Legal Business Name): THE GENESIS PROJECT, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2009
Last Update Date: 08/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 BOYSON SQUARE DR SUITE B
HIAWATHA IA
52233-2311
US

IV. Provider business mailing address

1601 BOYSON SQUARE DR SUITE B
HIAWATHA IA
52233-2311
US

V. Phone/Fax

Practice location:
  • Phone: 319-294-9890
  • Fax: 319-294-9896
Mailing address:
  • Phone: 319-294-9890
  • Fax: 319-294-9896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number27190
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number27190
License Number StateIA

VIII. Authorized Official

Name: DR. TODD ALLAN CONWAY
Title or Position: OWNER
Credential: M.D.
Phone: 319-294-9890