Healthcare Provider Details

I. General information

NPI: 1114276029
Provider Name (Legal Business Name): COVENANT CARE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2012
Last Update Date: 09/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 E 4TH ST
SALEM MO
65560-1547
US

IV. Provider business mailing address

PO BOX 110
FREDERICKTOWN MO
63645-0110
US

V. Phone/Fax

Practice location:
  • Phone: 573-783-6256
  • Fax: 573-783-8148
Mailing address:
  • Phone: 573-783-6256
  • Fax: 573-783-8148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number1008
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number1008
License Number StateMO

VIII. Authorized Official

Name: MR. WARREN KEITH REAGAN
Title or Position: OWNER
Credential:
Phone: 573-783-6256