Provider Demographics
NPI:1023190824
Name:COVENANT LIVING WEST
Entity Type:Organization
Organization Name:COVENANT LIVING WEST
Other - Org Name:COVENANT SHORES HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT OF HEALTH SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MALZAHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-878-4430
Mailing Address - Street 1:9150 FORTUNA DRIVE
Mailing Address - Street 2:
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040-3133
Mailing Address - Country:US
Mailing Address - Phone:206-268-3000
Mailing Address - Fax:206-236-1438
Practice Address - Street 1:9107 FORTUNA DR
Practice Address - Street 2:
Practice Address - City:MERCER ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98040-3132
Practice Address - Country:US
Practice Address - Phone:206-268-3000
Practice Address - Fax:206-236-1438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1231314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4112314Medicaid
WA505504Medicare Oscar/Certification