Provider Demographics
NPI:1528380748
Name:COVENANT MEDICAL CLINIC
Entity Type:Organization
Organization Name:COVENANT MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOBOLANLE
Authorized Official - Middle Name:
Authorized Official - Last Name:FADARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-874-0850
Mailing Address - Street 1:2812 W DR MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6306
Mailing Address - Country:US
Mailing Address - Phone:813-874-0850
Mailing Address - Fax:
Practice Address - Street 1:2812 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6306
Practice Address - Country:US
Practice Address - Phone:813-874-0850
Practice Address - Fax:813-874-0590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-16
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL126336208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty