Healthcare Provider Details

I. General information

NPI: 1982900445
Provider Name (Legal Business Name): COVENANT HOME OF CHICAGO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2011
Last Update Date: 02/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 WEST FOSTER AVENUE
CHICAGO IL
60625-3510
US

IV. Provider business mailing address

2720 WEST FOSTER AVENUE
CHICAGO IL
60625-3510
US

V. Phone/Fax

Practice location:
  • Phone: 773-506-6900
  • Fax: 773-878-4530
Mailing address:
  • Phone: 773-506-6900
  • Fax: 773-878-4530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateIL

VIII. Authorized Official

Name: MR. DAVID G ERICKSON
Title or Position: VICE PRESIDENT
Credential: J.D.
Phone: 773-878-2294