Provider Demographics
NPI:1043671704
Name:THE COVINGTON'S COVE ASSISTED LIVING CENTER LLC
Entity Type:Organization
Organization Name:THE COVINGTON'S COVE ASSISTED LIVING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:MONTEZ
Authorized Official - Last Name:DELOACH
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:601-310-8014
Mailing Address - Street 1:510 MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-6816
Mailing Address - Country:US
Mailing Address - Phone:601-310-8014
Mailing Address - Fax:
Practice Address - Street 1:192 MARY MAGDALENE CHURCH RD
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401
Practice Address - Country:US
Practice Address - Phone:601-310-8014
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances