Provider Demographics
NPI:1093855355
Name:COVENANT CARE CENTER OF PADUCAH, LLC
Entity Type:Organization
Organization Name:COVENANT CARE CENTER OF PADUCAH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:SANBORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-717-5519
Mailing Address - Street 1:16203 CHASEMORE DR
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77379-6603
Mailing Address - Country:US
Mailing Address - Phone:832-717-5519
Mailing Address - Fax:832-717-5519
Practice Address - Street 1:800 7TH STREET
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:TX
Practice Address - Zip Code:79248
Practice Address - Country:US
Practice Address - Phone:806-492-3516
Practice Address - Fax:806-492-2366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4459314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX675404Medicare ID - Type UnspecifiedPROVIDER NUMBER