Provider Demographics
NPI:1558527390
Name:COVENTRY HOMESTEAD, LLC
Entity Type:Organization
Organization Name:COVENTRY HOMESTEAD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:BONEY
Authorized Official - Suffix:
Authorized Official - Credentials:MECHANICAL ENGINEER
Authorized Official - Phone:313-368-4649
Mailing Address - Street 1:19402 COVENTRY ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48203-4909
Mailing Address - Country:US
Mailing Address - Phone:313-368-4649
Mailing Address - Fax:313-368-4649
Practice Address - Street 1:19402 COVENTRY ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48203-4909
Practice Address - Country:US
Practice Address - Phone:313-368-4649
Practice Address - Fax:313-368-4649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS820289860311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home