Basic Information
| Provider Information | |||||||||
| NPI: | 1104171016 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GENOA HEALTHCARE, LLC | ||||||||
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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: | 2925 RUSSELL ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482074825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138792057 | ||||||||
| FaxNumber: | 3138792058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2012 | ||||||||
| LastUpdateDate: | 06/28/2022 | ||||||||
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| AuthorizedOfficialLastName: | DOUGLAS | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8154044871 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336L0003X | 5301009854 | MI | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2167534 | 01 | PK | OTHER | 1104171016 | 05 | MI | MEDICAID |