Basic Information
| Provider Information | |||||||||
| NPI: | 1205270675 | ||||||||
| 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: | 955 WATER ST STE P | ||||||||
| Address2: | |||||||||
| City: | KERRVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780283508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8308960256 | ||||||||
| FaxNumber: | 8307920667 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2013 | ||||||||
| LastUpdateDate: | 11/02/2022 | ||||||||
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| AuthorizedOfficialLastName: | BOHMER | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
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| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 2242311833 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X | 28530 | TX | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2140099 | 01 | PK | OTHER | 470892 | 05 | TX | MEDICAID |