Provider Demographics
NPI:1578678082
Name:COVENANT CARE OF O'FALLON, LLC
Entity Type:Organization
Organization Name:COVENANT CARE OF O'FALLON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:POTTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-632-3511
Mailing Address - Street 1:700 WEBER RD
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-2248
Mailing Address - Country:US
Mailing Address - Phone:618-632-3511
Mailing Address - Fax:618-632-3053
Practice Address - Street 1:700 WEBER RD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-2248
Practice Address - Country:US
Practice Address - Phone:618-632-3511
Practice Address - Fax:618-632-3053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1733880314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1733880Medicaid
145144Medicare ID - Type Unspecified