Provider Demographics
NPI:1437862695
Name:ARK COVERNANT
Entity Type:Organization
Organization Name:ARK COVERNANT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN
Authorized Official - Prefix:
Authorized Official - First Name:NGWI
Authorized Official - Middle Name:RITA
Authorized Official - Last Name:ETIENDEM
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:480-667-8101
Mailing Address - Street 1:44202 W GRANITE DR
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85139-8868
Mailing Address - Country:US
Mailing Address - Phone:480-667-8101
Mailing Address - Fax:
Practice Address - Street 1:45702 W STARLIGHT DR
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85139-6656
Practice Address - Country:US
Practice Address - Phone:480-667-8101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ873312201Medicaid