1912958364 NPI number — COVENANT HOME CARE LLC

Table of content: (NPI 1912958364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912958364 NPI number — COVENANT HOME CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COVENANT HOME 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:
1912958364
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/31/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
133 WEST LONG LAKE ROAD
Provider Second Line Business Mailing Address:
STE 150
Provider Business Mailing Address City Name:
BLOOMFIELD HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-593-6177
Provider Business Mailing Address Fax Number:
248-593-6002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1133 W LONG LAKE RD
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
BLOOMFIELD HILLS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48302-1983
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-593-6177
Provider Business Practice Location Address Fax Number:
248-593-6002
Provider Enumeration Date:
05/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
REEVES
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
ADMIN
Authorized Official Telephone Number:
248-593-6177

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4988105 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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