Provider Demographics
NPI:1932499621
Name:COVENANT HEALTHCARE LAB, LLC
Entity Type:Organization
Organization Name:COVENANT HEALTHCARE LAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:STEFANELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-719-9915
Mailing Address - Street 1:305 CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE 290
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-8181
Mailing Address - Country:US
Mailing Address - Phone:386-615-2100
Mailing Address - Fax:386-236-0862
Practice Address - Street 1:305 CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE 290
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8181
Practice Address - Country:US
Practice Address - Phone:386-615-2100
Practice Address - Fax:386-236-0862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-14
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10D1092594291U00000X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory