Provider Demographics
NPI:1114276029
Name:COVENANT CARE SERVICES, LLC
Entity Type:Organization
Organization Name:COVENANT CARE SERVICES, LLC
Other - Org Name:ASHLEY'S PLACE ADULT DAY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:REAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-783-6256
Mailing Address - Street 1:PO BOX 110
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:63645-0110
Mailing Address - Country:US
Mailing Address - Phone:573-783-6256
Mailing Address - Fax:573-783-8148
Practice Address - Street 1:407 E 4TH ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MO
Practice Address - Zip Code:65560-1547
Practice Address - Country:US
Practice Address - Phone:573-783-6256
Practice Address - Fax:573-783-8148
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COVENANT CARE SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-09-06
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1008311ZA0620X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1487749537Medicaid
MO1245370808Medicaid
MO1326188996Medicaid
MO1770623266Medicaid
MO1871823955Medicaid