Provider Demographics
NPI:1780761478
Name:COVENANT CARE CENTER OF QUANAH, LLC
Entity type:Organization
Organization Name:COVENANT CARE CENTER OF QUANAH, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
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 1:1106 W 14TH ST
Mailing Address - Street 2:
Mailing Address - City:QUANAH
Mailing Address - State:TX
Mailing Address - Zip Code:79252-6300
Mailing Address - Country:US
Mailing Address - Phone:940-663-2869
Mailing Address - Fax:940-663-6429
Practice Address - Street 1:1106 W 14TH ST
Practice Address - Street 2:
Practice Address - City:QUANAH
Practice Address - State:TX
Practice Address - Zip Code:79252-6300
Practice Address - Country:US
Practice Address - Phone:940-663-2869
Practice Address - Fax:940-663-6429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118688314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001013333Medicaid
TX001013333Medicaid