Provider Demographics
NPI:1093870594
Name:COVENANT HOSPICE INC
Entity Type:Organization
Organization Name:COVENANT HOSPICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:
Authorized Official - Last Name:CLENEAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-433-2155
Mailing Address - Street 1:5041 N 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-8916
Mailing Address - Country:US
Mailing Address - Phone:850-433-2155
Mailing Address - Fax:850-202-5819
Practice Address - Street 1:4215 KELSON AVE
Practice Address - Street 2:SUITE E
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-6502
Practice Address - Country:US
Practice Address - Phone:850-482-8520
Practice Address - Fax:850-482-8985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5025095251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU20OtherBLUE CROSS BLUE SHIELD
FL087517100Medicaid
FL087517100Medicaid
FL=========-002OtherTRICARE