Provider Demographics
NPI:1518144997
Name:COVENANT HEALTHCARE LAB
Entity Type:Organization
Organization Name:COVENANT HEALTHCARE LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EX DIRECTOR OF ADMINISTRATION
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAT
Authorized Official - Middle Name:E
Authorized Official - Last Name:OWEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-536-9270
Mailing Address - Street 1:4290 S HWY 27
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-8066
Mailing Address - Country:US
Mailing Address - Phone:352-536-9270
Mailing Address - Fax:352-536-9279
Practice Address - Street 1:3824 E US HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-1407
Practice Address - Country:US
Practice Address - Phone:386-719-9915
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAL320OtherMEDICARE PTAN