Healthcare Provider Details

I. General information

NPI: 1508197054
Provider Name (Legal Business Name): COVENANT CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2010
Last Update Date: 01/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7015 BROOKLYN BLVD SUITE 106
BROOKLYN CENTER MN
55429-1365
US

IV. Provider business mailing address

7015 BROOKLYN BLVD SUITE 106
BROOKLYN CENTER MN
55429-1376
US

V. Phone/Fax

Practice location:
  • Phone: 763-528-8303
  • Fax:
Mailing address:
  • Phone: 763-528-8303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. ODUWA AGANMWONYI
Title or Position: GENERAL MANAGER
Credential:
Phone: 763-528-8303