Provider Demographics
NPI:1649574211
Name:COVENANT FAMILY PRACTICE
Entity Type:Organization
Organization Name:COVENANT FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-245-1150
Mailing Address - Street 1:PO BOX 30594
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-0010
Mailing Address - Country:US
Mailing Address - Phone:931-245-1150
Mailing Address - Fax:931-245-0605
Practice Address - Street 1:1000 HIGHWAY 76
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-8405
Practice Address - Country:US
Practice Address - Phone:931-245-1150
Practice Address - Fax:931-245-0605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-22
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15390261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care