1124523675 NPI number — GENOA HEALTHCARE LLC

Table of content: (NPI 1124523675)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124523675 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:
GENOA HEALTHCARE, LLC
Provider Other Organization Name Type Code:
3
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:
1124523675
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
707 S GRADY WAY STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RENTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98057-3246
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:
7200 RHEA COUNTY HWY RM 6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37321-6288
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-402-9762
Provider Business Practice Location Address Fax Number:
423-775-8947
Provider Enumeration Date:
03/27/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BOHMER
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
224-231-1833

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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