1194074211 NPI number — GENOA HEALTHCARE LLC

Table of content: (NPI 1194074211)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194074211 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:
1194074211
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2024
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:
6801 E 117TH ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KANSAS CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64134-3701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-533-6843
Provider Business Practice Location Address Fax Number:
816-767-8399
Provider Enumeration Date:
09/05/2012

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: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • 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)