Provider Demographics
NPI:1528383254
Name:COVENANT HOSPICE, INC.
Entity Type:Organization
Organization Name:COVENANT HOSPICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:
Authorized Official - Last Name:CLENEAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-433-2155
Mailing Address - Street 1:5041 N 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-8916
Mailing Address - Country:US
Mailing Address - Phone:850-433-2155
Mailing Address - Fax:850-202-5819
Practice Address - Street 1:1545 RAYMOND DIEHL RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-1514
Practice Address - Country:US
Practice Address - Phone:850-575-4998
Practice Address - Fax:850-386-9161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-06
Last Update Date:2021-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL087517103251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL087517103Medicaid