MEDICARE: COVENANT LIVING AT SHANNONDALE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility		TN

General Provider Information

NPI Number	:	1396742334
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COVENANT LIVING AT SHANNONDALE

Provider Business Mailing Address
First Line	:	801 VANOSDALE RD
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37909-2497
Country	:	US
Telephone Number	:	865-690-3411
Fax Number	:	865-246-1799

Provider Business Practice Location Address
First Line	:	803 SHANNONDALE WAY
Second Line	:
City	:	MARYVILLE
State	:	TN
Zip	:	37803-5972
Country	:	US
Telephone Number	:	865-982-4599
Fax Number	:	865-982-3786

Authorized Official
Title or Position	:	SVP REIMBURSEMENT
Name	:	ELIZABETH A MALZAHN
Credential	:
Telephone Number	:	773-878-4430

Provider Enumeration Date	:	07/06/2005
Last Update Date	:	11/04/2024

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