Basic Information
Provider Information | |||||||||
NPI: | 1003067471 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GENOA HEALTHCARE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 707 S GRADY WAY STE 700 | ||||||||
Address2: |   | ||||||||
City: | RENTON | ||||||||
State: | WA | ||||||||
PostalCode: | 980573243 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2532180830 | ||||||||
FaxNumber: | 2532174306 | ||||||||
Practice Location | |||||||||
Address1: | 901 NE INDEPENDENCE AVE | ||||||||
Address2: |   | ||||||||
City: | LEES SUMMIT | ||||||||
State: | MO | ||||||||
PostalCode: | 640865544 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8163470075 | ||||||||
FaxNumber: | 8163470086 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/03/2008 | ||||||||
LastUpdateDate: | 11/04/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BOHMER | ||||||||
AuthorizedOfficialFirstName: | KAREN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
AuthorizedOfficialTelephone: | 2242311833 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/04/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 2008028915 | MO | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 333600000X | 2006025277 | MO | N |   | Suppliers | Pharmacy |   | 3336L0003X | 2008028915 | MO | Y |   | Suppliers | Pharmacy | Long Term Care Pharmacy |
No ID Information.