Provider Demographics
NPI:1487665980
Name:GENOA HEALTHCARE OF FL LLC
Entity Type:Organization
Organization Name:GENOA HEALTHCARE OF FL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTYN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:753-218-0862
Mailing Address - Street 1:510 EASTERN ST
Mailing Address - Street 2:
Mailing Address - City:AUBUURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1437 S BELCHER RD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33764-2829
Practice Address - Country:US
Practice Address - Phone:727-533-9073
Practice Address - Fax:727-533-9184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
FLPH221023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1020356OtherOTHER ID NUMBER-COMMERCIAL NUMBER