1396811550 NPI number — COVENANT CARE OF JACKSONVILLE LLC

Table of content: (NPI 1396811550)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396811550 NPI number — COVENANT CARE OF JACKSONVILLE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COVENANT CARE OF JACKSONVILLE 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:
MODERN CARE CONVALESCENT AND NURSING HOME
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:
1396811550
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 MOUNTAIN CREEK ROAD
Provider Second Line Business Mailing Address:
SUITE 350
Provider Business Mailing Address City Name:
CHATTANOOGA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37405-6103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-870-3153
Provider Business Mailing Address Fax Number:
423-870-3196

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 WEST WALNUT STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62650-1134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-245-4183
Provider Business Practice Location Address Fax Number:
217-243-2915
Provider Enumeration Date:
11/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
POTTS
Authorized Official First Name:
GARY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
423-870-3153

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , with the licence number:  1764855 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 314000000X , with the licence number: 0047852 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0036301 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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