Provider Demographics
NPI:1255574265
Name:COVENANT COMMUNITY CARE, INC.
Entity type:Organization
Organization Name:COVENANT COMMUNITY CARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:GRIEBEL
Authorized Official - Last Name:CHAVEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-554-0485
Mailing Address - Street 1:559 W GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48216-2200
Mailing Address - Country:US
Mailing Address - Phone:313-554-0485
Mailing Address - Fax:313-554-3885
Practice Address - Street 1:1700 WATERMAN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48209-2022
Practice Address - Country:US
Practice Address - Phone:313-841-1612
Practice Address - Fax:313-554-1918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-07
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704195855261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI231928Medicare Oscar/Certification