Provider Demographics
NPI:1669776092
Name:COVENANT OF LOVE UUL CORPORATION
Entity type:Organization
Organization Name:COVENANT OF LOVE UUL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, ADMINISTRATOR, CADC
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:WHITE
Authorized Official - Last Name:BYNUM
Authorized Official - Suffix:
Authorized Official - Credentials:DR STUDENT HCA
Authorized Official - Phone:702-810-4830
Mailing Address - Street 1:408 ELDORADO HILLS CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89110-5646
Mailing Address - Country:US
Mailing Address - Phone:702-810-4830
Mailing Address - Fax:702-255-7766
Practice Address - Street 1:408 ELDORADO HILLS CT
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110-5646
Practice Address - Country:US
Practice Address - Phone:702-810-4830
Practice Address - Fax:702-255-7766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-28
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5061AGC-1302F00000X
NV5464TLF-1251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV251S00000XMedicaid
NV251S00000XMedicaid