Provider Demographics
NPI:1205905718
Name:COVENANT MEDICAL SUPPLY, INC.
Entity type:Organization
Organization Name:COVENANT MEDICAL SUPPLY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:LLOYD
Authorized Official - Middle Name:UDONWA
Authorized Official - Last Name:NSEK
Authorized Official - Suffix:SR
Authorized Official - Credentials:MIN
Authorized Official - Phone:909-815-5635
Mailing Address - Street 1:351 WILKERSON AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92570-2203
Mailing Address - Country:US
Mailing Address - Phone:951-943-3900
Mailing Address - Fax:951-943-3939
Practice Address - Street 1:351 WILKERSON AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92570-2203
Practice Address - Country:US
Practice Address - Phone:951-943-3900
Practice Address - Fax:951-943-3939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47574332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6028690001Medicare NSC