Healthcare Provider Details

I. General information

NPI: 1275663445
Provider Name (Legal Business Name): COVENANT CARE MIDWEST, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PERRYMAN ST
LEBANON IL
62254-1356
US

IV. Provider business mailing address

1 PERRYMAN ST
LEBANON IL
62254-1356
US

V. Phone/Fax

Practice location:
  • Phone: 618-537-6165
  • Fax: 618-537-4021
Mailing address:
  • Phone: 618-537-6165
  • Fax: 618-537-4021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0042838
License Number StateIL

VIII. Authorized Official

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