Provider Demographics
NPI:1922536671
Name:COVENANT MOBILE HEALTHCARE LLC
Entity Type:Organization
Organization Name:COVENANT MOBILE HEALTHCARE LLC
Other - Org Name:FAMILY FIRST PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:RICKS
Authorized Official - Suffix:JR
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:979-248-1586
Mailing Address - Street 1:732 E HENDERSON RD
Mailing Address - Street 2:
Mailing Address - City:ANGLETON
Mailing Address - State:TX
Mailing Address - Zip Code:77515-8463
Mailing Address - Country:US
Mailing Address - Phone:979-248-1586
Mailing Address - Fax:979-318-5594
Practice Address - Street 1:FAMILY FIRST PRIMARY CARE
Practice Address - Street 2:732 E. HENDERSON RD
Practice Address - City:ANGLETON
Practice Address - State:TX
Practice Address - Zip Code:77515
Practice Address - Country:US
Practice Address - Phone:979-248-1586
Practice Address - Fax:979-318-5594
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COVENANT MOBILE HEALTHCARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-05-25
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3675498Medicaid