Provider Demographics
NPI:1750093241
Name:COVENANT HOME HEALTH CARE AGENCY LLC
Entity type:Organization
Organization Name:COVENANT HOME HEALTH CARE AGENCY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:OMONIYI
Authorized Official - Middle Name:MAUDE
Authorized Official - Last Name:ANNIE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:352-405-7077
Mailing Address - Street 1:1731 NW 6TH ST STE B1
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32609-8515
Mailing Address - Country:US
Mailing Address - Phone:240-581-2279
Mailing Address - Fax:407-602-0015
Practice Address - Street 1:1731 NW 6TH ST STE B1
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32609-8515
Practice Address - Country:US
Practice Address - Phone:240-581-2279
Practice Address - Fax:407-602-0015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-16
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL117486900Medicaid