Provider Demographics
NPI:1376687897
Name:COVENANT CONNECTIONS HOME CARE, LLC
Entity Type:Organization
Organization Name:COVENANT CONNECTIONS HOME CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:JOYCE
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:313-592-1517
Mailing Address - Street 1:18440 W MCNICHOLS RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-4161
Mailing Address - Country:US
Mailing Address - Phone:313-592-1517
Mailing Address - Fax:313-592-1530
Practice Address - Street 1:18440 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-4161
Practice Address - Country:US
Practice Address - Phone:313-592-1517
Practice Address - Fax:313-592-1530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-17
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1376687897OtherOMNICARE
MIIE911OtherBLUE CROSS/BLUE SHEILD
MI23-7776OtherMEDICARE PTAN