Provider Demographics
NPI:1548564511
Name:GENOA HEALTHCARE CLINICAL LABORATORY LLC
Entity Type:Organization
Organization Name:GENOA HEALTHCARE CLINICAL LABORATORY LLC
Other - Org Name:GENOA HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:STROETZ
Authorized Official - Suffix:
Authorized Official - Credentials:MT ASCP
Authorized Official - Phone:651-917-4029
Mailing Address - Street 1:18300 CASCADE AVE S
Mailing Address - Street 2:SUITE 251
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98188-4746
Mailing Address - Country:US
Mailing Address - Phone:425-679-5692
Mailing Address - Fax:206-275-0114
Practice Address - Street 1:3101 OLD HIGHWAY 8
Practice Address - Street 2:SUITE 203-A
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-1072
Practice Address - Country:US
Practice Address - Phone:952-388-0400
Practice Address - Fax:651-304-1902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-05
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory