Healthcare Provider Details

I. General information

NPI: 1538506514
Provider Name (Legal Business Name): COVENANT HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2013
Last Update Date: 05/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1692 S SANTA FE AVE 62
SAN JACINTO CA
92583-5067
US

IV. Provider business mailing address

1692 S SANTA FE AVE 62
SAN JACINTO CA
92583-5067
US

V. Phone/Fax

Practice location:
  • Phone: 951-330-6236
  • Fax: 951-654-8639
Mailing address:
  • Phone: 951-330-6236
  • Fax: 951-654-8639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number00240076
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License Number00240076
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number00240076
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number00240076
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number00767135
License Number StateCA

VIII. Authorized Official

Name: MR. OLUMIDE JOHNSON
Title or Position: COO
Credential: CNA
Phone: 951-330-6236