1073929220 NPI number — GENOA HEALTHCARE, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073929220 NPI number — GENOA HEALTHCARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GENOA HEALTHCARE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073929220
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 77030
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55480-7730
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-218-0830
Provider Business Mailing Address Fax Number:
253-217-4306

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
975B KINGSVIEW DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45036-9562
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
412-931-3131
Provider Business Practice Location Address Fax Number:
412-223-5384
Provider Enumeration Date:
07/09/2014

Additional Information

Authorized Official

Authorized Official Last Name:
HENNESSY
Authorized Official First Name:
NATASHA
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF PHARMACY OFFICER
Authorized Official Telephone Number:
612-722-4249

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: CLPH.0224343600 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2146668 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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