1053487140 NPI number — THE COVENANT ADOLESCENT CHEMICAL DEPENDENCY TREATMENT & PREVENTION CEN

Table of content: (NPI 1053487140)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053487140 NPI number — THE COVENANT ADOLESCENT CHEMICAL DEPENDENCY TREATMENT & PREVENTION CEN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE COVENANT ADOLESCENT CHEMICAL DEPENDENCY TREATMENT & PREVENTION CEN
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THE COVENANT, INC.
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053487140
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1515 W 29TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44113-2906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-574-9000
Provider Business Mailing Address Fax Number:
216-664-6534

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1515 W 29TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44113-2906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-574-9000
Provider Business Practice Location Address Fax Number:
216-664-6534
Provider Enumeration Date:
11/28/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PIAZZA
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
216-574-9000

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  6782 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)