Provider Demographics
NPI:1629219290
Name:GENOA HEALTHCARE LLC
Entity Type:Organization
Organization Name:GENOA HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOHMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-231-1833
Mailing Address - Street 1:707 S GRADY WAY STE 400
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-3246
Mailing Address - Country:US
Mailing Address - Phone:877-719-6349
Mailing Address - Fax:877-719-6362
Practice Address - Street 1:701 SHADOW LN STE 110
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4131
Practice Address - Country:US
Practice Address - Phone:702-382-4176
Practice Address - Fax:702-382-4822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-11
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPH025583336C0003X, 3336C0004X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CN059AOtherMEDICARE MASS IMMUNIZATION ROSTER BILLER
NV1629219290Medicaid
NV6331770001Medicare NSC