Healthcare Provider Details

I. General information

NPI: 1780128520
Provider Name (Legal Business Name): GENOA HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2016
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1128 NW HARRIMAN ST STE 161
BEND OR
97703-1947
US

IV. Provider business mailing address

707 S GRADY WAY STE 400
RENTON WA
98057-3246
US

V. Phone/Fax

Practice location:
  • Phone: 541-633-7159
  • Fax: 541-359-2651
Mailing address:
  • Phone: 253-218-0830
  • Fax: 253-217-4306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KAREN BOHMER
Title or Position: SECRETARY
Credential:
Phone: 224-231-1833