1205197456 NPI number — COVENANT CARE IN-HOME AGENCY LLC.

Table of content: JOHANNY GLISEL PADILLA SANCHEZ (NPI 1891687539)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205197456 NPI number — COVENANT CARE IN-HOME AGENCY LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COVENANT CARE IN-HOME AGENCY LLC.
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:
1205197456
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5979 N. POINTE BLVD.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST. LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-381-0928
Provider Business Mailing Address Fax Number:
314-383-2873

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6000 WEST FLORISSANT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST. LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63136
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-381-0928
Provider Business Practice Location Address Fax Number:
314-383-2873
Provider Enumeration Date:
06/05/2012

Additional Information

Authorized Official

Authorized Official Last Name:
HARRIS
Authorized Official First Name:
GELIS
Authorized Official Middle Name:
DEON
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
314-898-6916

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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