Provider Demographics
NPI:1568167708
Name:COVENANT RESIDENTIAL SERVICES LLC
Entity Type:Organization
Organization Name:COVENANT RESIDENTIAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ZABRON
Authorized Official - Middle Name:
Authorized Official - Last Name:NDIKUMUKIZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-252-8470
Mailing Address - Street 1:696 WESTBROOK ST APT 13A
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-1987
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:696 WESTBROOK ST APT 13A
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-1987
Practice Address - Country:US
Practice Address - Phone:207-252-8470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities