Provider Demographics
NPI:1467728303
Name:COVENANT OPTIMIZED LIVING LLC
Entity Type:Organization
Organization Name:COVENANT OPTIMIZED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KARI
Authorized Official - Middle Name:J
Authorized Official - Last Name:HAYWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-233-3700
Mailing Address - Street 1:4910 FREDERICK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3246
Mailing Address - Country:US
Mailing Address - Phone:816-233-3700
Mailing Address - Fax:816-233-3754
Practice Address - Street 1:4910 FREDERICK AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3246
Practice Address - Country:US
Practice Address - Phone:816-233-3700
Practice Address - Fax:816-233-3754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-26
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO112571207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOR517867Medicare PIN