Basic Information
| Provider Information | |||||||||
| NPI: | 1053696914 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GENOA HEALTHCARE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GENOA HEALTHCARE OF MINNESOTA LLC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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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: | 2537354741 | ||||||||
| Practice Location | |||||||||
| Address1: | 1155 FORD RD STE C | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122842197 | ||||||||
| FaxNumber: | 6128086759 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2011 | ||||||||
| LastUpdateDate: | 10/31/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOHMER | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 2242311833 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 263771 | MN | N | Suppliers | Durable Medical Equipment & Medical Supplies | 333600000X | 263771 | MN | N | Suppliers | Pharmacy | 3336L0003X | 263771 | MN | N | Suppliers | Pharmacy | Long Term Care Pharmacy | 3336L0003X | 264642 | MN | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1053696914 | 05 | MN | MEDICAID |