Provider Demographics
NPI:1538506514
Name:COVENANT HEALTHCARE, LLC
Entity Type:Organization
Organization Name:COVENANT HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:OLUMIDE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:CNA
Authorized Official - Phone:951-330-6236
Mailing Address - Street 1:1692 S SANTA FE AVE
Mailing Address - Street 2:62
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92583-5067
Mailing Address - Country:US
Mailing Address - Phone:951-330-6236
Mailing Address - Fax:951-654-8639
Practice Address - Street 1:1692 S SANTA FE AVE
Practice Address - Street 2:62
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-5067
Practice Address - Country:US
Practice Address - Phone:951-330-6236
Practice Address - Fax:951-654-8639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-30
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00240076253Z00000X, 372500000X, 372600000X, 374U00000X
CA00767135376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
No372500000XNursing Service Related ProvidersChore ProviderGroup - Multi-Specialty
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Multi-Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
No376K00000XNursing Service Related ProvidersNurse's AideGroup - Multi-Specialty