Provider Demographics
NPI:1821589615
Name:COVENANT HOUSE, INC
Entity Type:Organization
Organization Name:COVENANT HOUSE, INC
Other - Org Name:COVENANT HOUSE WELLNESS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, REIMBURSEMENT SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-844-1020
Mailing Address - Street 1:2385 W CHELTENHAM AVE.
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19150
Mailing Address - Country:US
Mailing Address - Phone:215-877-7300
Mailing Address - Fax:215-844-1020
Practice Address - Street 1:2385 W CHELTENHAM AVE.
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19150
Practice Address - Country:US
Practice Address - Phone:215-877-7300
Practice Address - Fax:215-844-1020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA032220261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007564460003Medicaid