Healthcare Provider Details

I. General information

NPI: 1417437005
Provider Name (Legal Business Name): COVENANT MEMORY CARE CENTER AT THE JOYCE GOLDENBERG CAMPUS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2018
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10075 HILLVIEW DR
PENSACOLA FL
32514-5469
US

IV. Provider business mailing address

5041 N 12TH AVE
PENSACOLA FL
32504-8916
US

V. Phone/Fax

Practice location:
  • Phone: 850-484-3529
  • Fax: 888-239-6554
Mailing address:
  • Phone: 850-433-2155
  • Fax: 850-478-7517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL13110
License Number StateFL

VIII. Authorized Official

Name: ODIN BERG
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 850-433-2155