Healthcare Provider Details

I. General information

NPI: 1396811550
Provider Name (Legal Business Name): COVENANT CARE OF JACKSONVILLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 07/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 WEST WALNUT STREET
JACKSONVILLE IL
62650-1134
US

IV. Provider business mailing address

1200 MOUNTAIN CREEK ROAD SUITE 350
CHATTANOOGA TN
37405-6103
US

V. Phone/Fax

Practice location:
  • Phone: 217-245-4183
  • Fax: 217-243-2915
Mailing address:
  • Phone: 423-870-3153
  • Fax: 423-870-3196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number1764855
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0047852
License Number StateIL

VIII. Authorized Official

Name: GARY L POTTS
Title or Position: MANAGER
Credential:
Phone: 423-870-3153