Provider Demographics
NPI:1942243209
Name:COVENANT REHAB CLINIC, LLC
Entity Type:Organization
Organization Name:COVENANT REHAB CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:BARTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-646-0022
Mailing Address - Street 1:740 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:MO
Mailing Address - Zip Code:64601-3042
Mailing Address - Country:US
Mailing Address - Phone:660-646-0022
Mailing Address - Fax:660-646-1553
Practice Address - Street 1:740 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:MO
Practice Address - Zip Code:64601-3042
Practice Address - Country:US
Practice Address - Phone:660-646-0022
Practice Address - Fax:660-646-1553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1183 & 00943225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO34276019OtherBLUE CROSS BLUE SHIELD
MODC2515OtherRAIL ROAD MEDICARE
MOR340000Medicare ID - Type Unspecified