Healthcare Provider Details

I. General information

NPI: 1366959561
Provider Name (Legal Business Name): COVENANT RECOVERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2018
Last Update Date: 01/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3007 MEMORIAL PKWY SW STE C
HUNTSVILLE AL
35801-5394
US

IV. Provider business mailing address

3007 MEMORIAL PKWY SW STE C
HUNTSVILLE AL
35801-5394
US

V. Phone/Fax

Practice location:
  • Phone: 256-882-2003
  • Fax: 256-705-4630
Mailing address:
  • Phone: 256-882-2003
  • Fax: 256-705-4630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: DR. KENNETH DEAN WILLIS
Title or Position: SOLE MEMBER
Credential: MD
Phone: 256-882-2003