Provider Demographics
NPI:1396811550
Name:COVENANT CARE OF JACKSONVILLE LLC
Entity type:Organization
Organization Name:COVENANT CARE OF JACKSONVILLE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:POTTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-870-3153
Mailing Address - Street 1:1200 MOUNTAIN CREEK ROAD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37405-6103
Mailing Address - Country:US
Mailing Address - Phone:423-870-3153
Mailing Address - Fax:423-870-3196
Practice Address - Street 1:1500 WEST WALNUT STREET
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-1134
Practice Address - Country:US
Practice Address - Phone:217-245-4183
Practice Address - Fax:217-243-2915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0047852314000000X
IL1764855313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0036301Medicaid
IL0036301Medicaid