Healthcare Provider Details

I. General information

NPI: 1699523977
Provider Name (Legal Business Name): COVENANT BEHAVIORAL HEALTH RESIDENTIAL FACILITY.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2024
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5322 W SHUMWAY FARM RD
LAVEEN AZ
85339-6925
US

IV. Provider business mailing address

5322 W SHUMWAY FARM RD
LAVEEN AZ
85339-6925
US

V. Phone/Fax

Practice location:
  • Phone: 623-330-7509
  • Fax:
Mailing address:
  • Phone: 623-330-7509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State

VIII. Authorized Official

Name: ADANE HAILE NIGANI
Title or Position: ADMINISTRATOR
Credential: BHPP
Phone: 623-330-7509