Provider Demographics
NPI:1225159403
Name:COVENANT MEDICAL DEVICES AND SUPPLIES
Entity Type:Organization
Organization Name:COVENANT MEDICAL DEVICES AND SUPPLIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ISRAEL
Authorized Official - Middle Name:NDUBUISI
Authorized Official - Last Name:OTUWA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-754-7061
Mailing Address - Street 1:199A W JOE ORR ROAD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411
Mailing Address - Country:US
Mailing Address - Phone:708-754-7061
Mailing Address - Fax:708-754-8516
Practice Address - Street 1:199A W JOE ORR ROAD
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411
Practice Address - Country:US
Practice Address - Phone:708-754-7061
Practice Address - Fax:708-754-8516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL203.000482332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5156640002Medicare ID - Type Unspecified