Provider Demographics
NPI:1720419641
Name:COVENANT CARE SERVICES LLC
Entity Type:Organization
Organization Name:COVENANT CARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BLONDELL
Authorized Official - Middle Name:P
Authorized Official - Last Name:SIMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-542-6396
Mailing Address - Street 1:1208 SLOAN ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-3442
Mailing Address - Country:US
Mailing Address - Phone:336-542-6396
Mailing Address - Fax:336-694-1675
Practice Address - Street 1:1208 SLOAN ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-3442
Practice Address - Country:US
Practice Address - Phone:336-339-9788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-02
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL 041 10883104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness