Healthcare Provider Details

I. General information

NPI: 1982925509
Provider Name (Legal Business Name): COVENANT CARE ENNOBLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2010
Last Update Date: 06/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 PASADENA DR
DUBUQUE IA
52001-0808
US

IV. Provider business mailing address

2000 PASADENA DR
DUBUQUE IA
52001-0808
US

V. Phone/Fax

Practice location:
  • Phone: 563-577-1076
  • Fax: 563-584-0671
Mailing address:
  • Phone: 563-577-1076
  • Fax: 563-584-0671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number310764
License Number StateIA

VIII. Authorized Official

Name: CAROL SPARKS
Title or Position: DIRECTOR OF REIMBURSEMENT
Credential:
Phone: 949-349-1200