Basic Information
| Provider Information | |||||||||
| NPI: | 1053478875 | ||||||||
| 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: | 49 KESSEL CT | ||||||||
| Address2: | ROOM 123 | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537116200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082511838 | ||||||||
| FaxNumber: | 6082512184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2007 | ||||||||
| LastUpdateDate: | 11/07/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| 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 | 333600000X | N | Suppliers | Pharmacy | 3336L0003X | 9424-42 | WI | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2110958 | 01 | PK | OTHER | 33293600 | 05 | WI | MEDICAID |