Provider Demographics
NPI:1922142215
Name:COVENANT SLEEP CLINIC OF OXFORD, LLC
Entity Type:Organization
Organization Name:COVENANT SLEEP CLINIC OF OXFORD, LLC
Other - Org Name:SLEEP UNLIMITED OF OXFORD, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:K
Authorized Official - Last Name:GOWEN
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:662-236-7807
Mailing Address - Street 1:2908 SOUTH LAMAR BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655
Mailing Address - Country:US
Mailing Address - Phone:662-236-7807
Mailing Address - Fax:662-236-7854
Practice Address - Street 1:2908 SOUTH LAMAR BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655
Practice Address - Country:US
Practice Address - Phone:662-236-7807
Practice Address - Fax:662-236-7854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS512G470003Medicare UPIN
MS04327009Medicaid