Provider Demographics
NPI:1831281609
Name:COVENANT PLACE OF WAXAHACHIE
Entity Type:Organization
Organization Name:COVENANT PLACE OF WAXAHACHIE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & COO
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHANNESSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-770-5600
Mailing Address - Street 1:14160 DALLAS PKWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-4319
Mailing Address - Country:US
Mailing Address - Phone:972-770-5600
Mailing Address - Fax:972-770-5666
Practice Address - Street 1:401 SOLON RD
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-1328
Practice Address - Country:US
Practice Address - Phone:972-935-9363
Practice Address - Fax:972-923-3289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117586310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001014421OtherCBA CONTRACT #
TX001015630Medicaid