Healthcare Provider Details

I. General information

NPI: 1225159403
Provider Name (Legal Business Name): COVENANT MEDICAL DEVICES AND SUPPLIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199A W JOE ORR ROAD
CHICAGO HEIGHTS IL
60411
US

IV. Provider business mailing address

199A W JOE ORR ROAD
CHICAGO HEIGHTS IL
60411
US

V. Phone/Fax

Practice location:
  • Phone: 708-754-7061
  • Fax: 708-754-8516
Mailing address:
  • Phone: 708-754-7061
  • Fax: 708-754-8516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number203.000482
License Number StateIL

VIII. Authorized Official

Name: MR. ISRAEL NDUBUISI OTUWA
Title or Position: MANAGING DIRECTOR
Credential:
Phone: 708-754-7061