Provider Demographics
NPI:1376501510
Name:GENOA HEALTHCARE OF MINNESOTA, LLC
Entity Type:Organization
Organization Name:GENOA HEALTHCARE OF MINNESOTA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SITE IMPLEMENTATION
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:KERSAVAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-601-2122
Mailing Address - Street 1:510 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-5502
Mailing Address - Country:US
Mailing Address - Phone:360-218-0830
Mailing Address - Fax:
Practice Address - Street 1:825 S 8TH ST
Practice Address - Street 2:SUITE SL-10
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-1208
Practice Address - Country:US
Practice Address - Phone:612-332-6522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN262600-0333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy