Provider Demographics
NPI:1235671231
Name:COVENANT PAIN THERAPIES CENTER, INC
Entity Type:Organization
Organization Name:COVENANT PAIN THERAPIES CENTER, INC
Other - Org Name:COVENANT PAIN CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GOURD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-705-4406
Mailing Address - Street 1:PO BOX 18084
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35804-8084
Mailing Address - Country:US
Mailing Address - Phone:256-882-2003
Mailing Address - Fax:256-705-4630
Practice Address - Street 1:3007 MEMORIAL PKWY SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-5393
Practice Address - Country:US
Practice Address - Phone:256-882-2003
Practice Address - Fax:256-705-4630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-08
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12320208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty