Provider Demographics
NPI:1457408387
Name:COVENANT CARE CENTER OF BIG SPRING LLC MOUNTAINVIEW LODGE
Entity Type:Organization
Organization Name:COVENANT CARE CENTER OF BIG SPRING LLC MOUNTAINVIEW LODGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:SANBORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-717-5519
Mailing Address - Street 1:2009 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:BIG SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:79720-5909
Mailing Address - Country:US
Mailing Address - Phone:432-263-1271
Mailing Address - Fax:432-263-5338
Practice Address - Street 1:2009 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:BIG SPRING
Practice Address - State:TX
Practice Address - Zip Code:79720-5909
Practice Address - Country:US
Practice Address - Phone:432-263-1271
Practice Address - Fax:432-263-5338
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COVENANT CARE CENTER OF BIG SPRING LLC MOUNTAINVIEW LODGE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-04
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4921Medicaid
TX4921Medicaid