Basic Information
| Provider Information | |||||||||
| NPI: | 1013289610 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GENOA HEALTHCARE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GENOA HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| 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: | 2662 ELMWOOD RD | ||||||||
| Address2: | STE. 101 | ||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611031573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8155160246 | ||||||||
| FaxNumber: | 8156391355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2012 | ||||||||
| LastUpdateDate: | 11/07/2022 | ||||||||
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| AuthorizedOfficialLastName: | BOHMER | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 2242311833 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336L0003X | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | FG3083540 | 01 | DEA # | OTHER | 320.010221 | 01 | IL | CONTROLLED SUBSTANCE # | OTHER | 054.017839 | 01 | IL | PHARMACY LICENSE # | OTHER | 1486491 | 01 | NCPDP # | OTHER |