1245234897 NPI number — COVENANT CARE LLC

Table of content: (NPI 1245234897)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245234897 NPI number — COVENANT CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COVENANT CARE 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:
1245234897
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:
PO BOX 398
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FALL CREEK
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54742-0398
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-877-2411
Provider Business Mailing Address Fax Number:
715-877-2416

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
344 W LINCOLN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FALL CREEK
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54742-9397
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-877-2411
Provider Business Practice Location Address Fax Number:
715-877-2416
Provider Enumeration Date:
06/10/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HALBLEIB
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
CHARLES
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
715-877-2411

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  2073 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 20190400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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