1528362753 NPI number — COVENANT WAY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528362753 NPI number — COVENANT WAY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COVENANT WAY
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:
Provider Other Organization Name Type Code:
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:
1528362753
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 307
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUE WEST
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29639-0307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-379-2570
Provider Business Mailing Address Fax Number:
864-379-2571

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18 FRANK PRESSLY DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUE WEST
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29639-0307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-379-2570
Provider Business Practice Location Address Fax Number:
864-379-2570
Provider Enumeration Date:
01/03/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PRIDMORE
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
864-379-2570

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NCF-0775 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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