Healthcare Provider Details

I. General information

NPI: 1548564511
Provider Name (Legal Business Name): GENOA HEALTHCARE CLINICAL LABORATORY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2011
Last Update Date: 07/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 OLD HIGHWAY 8 SUITE 203-A
ROSEVILLE MN
55113-1072
US

IV. Provider business mailing address

18300 CASCADE AVE S SUITE 251
TUKWILA WA
98188-4746
US

V. Phone/Fax

Practice location:
  • Phone: 952-388-0400
  • Fax: 651-304-1902
Mailing address:
  • Phone: 425-679-5692
  • Fax: 206-275-0114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MR. PHILLIP RAYMOND STROETZ
Title or Position: LABORATORY DIRECTOR
Credential: MT ASCP
Phone: 651-917-4029