Provider Demographics
NPI:1114066735
Name:COVENANT HOMES LLC
Entity Type:Organization
Organization Name:COVENANT HOMES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:INGER
Authorized Official - Middle Name:D
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-553-0129
Mailing Address - Street 1:8214 FREDONIA RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23227-1532
Mailing Address - Country:US
Mailing Address - Phone:804-553-0129
Mailing Address - Fax:804-553-0130
Practice Address - Street 1:8214 FREDONIA RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23227-1532
Practice Address - Country:US
Practice Address - Phone:804-553-0129
Practice Address - Fax:804-553-0130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA735-01-001320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities