Provider Demographics
NPI:1598274664
Name:COVENANT HOSPICE,INC
Entity Type:Organization
Organization Name:COVENANT HOSPICE,INC
Other - Org Name:COVENANT HOSPICE INPATIENT UNIT AT SACRED HEART HOSPITAL
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ODIN
Authorized Official - Middle Name:G
Authorized Official - Last Name:BERG
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:850-202-5803
Practice Address - Street 1:5151 N 9TH AVE FL 1
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8721
Practice Address - Country:US
Practice Address - Phone:850-262-7830
Practice Address - Fax:850-598-2753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-21
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5025095315D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015986100Medicaid