1114276029 NPI number — COVENANT CARE SERVICES, LLC

Table of content: (NPI 1114276029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114276029 NPI number — COVENANT CARE SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COVENANT CARE SERVICES, 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:
6
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:
1114276029
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREDERICKTOWN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63645-0110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-783-6256
Provider Business Mailing Address Fax Number:
573-783-8148

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
407 E 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65560-1547
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-783-6256
Provider Business Practice Location Address Fax Number:
573-783-8148
Provider Enumeration Date:
09/06/2012

Additional Information

Authorized Official

Authorized Official Last Name:
REAGAN
Authorized Official First Name:
WARREN
Authorized Official Middle Name:
KEITH
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
573-783-6256

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X , with the licence number:  1008 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 320900000X , with the licence number: 1008 , 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)

  • Identifier: 1487749537 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1245370808 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1326188996 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1770623266 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1871823955 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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