Provider Demographics
NPI:1477811545
Name:COVENANT HOLISTIC HEALTHCARE SERVICES INC
Entity Type:Organization
Organization Name:COVENANT HOLISTIC HEALTHCARE SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-310-2235
Mailing Address - Street 1:2388 RIVER HILLS LN
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-4937
Mailing Address - Country:US
Mailing Address - Phone:630-310-2235
Mailing Address - Fax:630-226-5699
Practice Address - Street 1:2388 RIVER HILLS LN
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60490-4937
Practice Address - Country:US
Practice Address - Phone:630-310-2235
Practice Address - Fax:630-226-5699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-26
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3719OtherMEDICARE PTAN