Provider Demographics
NPI:1245234897
Name:COVENANT CARE LLC
Entity Type:Organization
Organization Name:COVENANT CARE LLC
Other - Org Name:FALL CREEK VALLEY CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:HALBLEIB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-877-2411
Mailing Address - Street 1:PO BOX 398
Mailing Address - Street 2:
Mailing Address - City:FALL CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:54742-0398
Mailing Address - Country:US
Mailing Address - Phone:715-877-2411
Mailing Address - Fax:715-877-2416
Practice Address - Street 1:344 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:FALL CREEK
Practice Address - State:WI
Practice Address - Zip Code:54742-9397
Practice Address - Country:US
Practice Address - Phone:715-877-2411
Practice Address - Fax:715-877-2416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2073314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20190400Medicaid
WI525460Medicare ID - Type Unspecified