Provider Demographics
NPI:1629028352
Name:COVENANT HEALTH & REHAB OF PICAYUNE, LP
Entity Type:Organization
Organization Name:COVENANT HEALTH & REHAB OF PICAYUNE, LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:ULLERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-937-7994
Mailing Address - Street 1:1620 READ RD
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-2710
Mailing Address - Country:US
Mailing Address - Phone:601-798-1811
Mailing Address - Fax:601-798-2362
Practice Address - Street 1:1620 READ RD
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-2710
Practice Address - Country:US
Practice Address - Phone:601-798-1811
Practice Address - Fax:601-798-2362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS593314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0220283Medicaid
MS0220283Medicaid