Healthcare Provider Details

I. General information

NPI: 1205197456
Provider Name (Legal Business Name): COVENANT CARE IN-HOME AGENCY LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2012
Last Update Date: 06/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 WEST FLORISSANT
ST. LOUIS MO
63136
US

IV. Provider business mailing address

5979 N. POINTE BLVD.
ST. LOUIS MO
63147
US

V. Phone/Fax

Practice location:
  • Phone: 314-381-0928
  • Fax: 314-383-2873
Mailing address:
  • Phone: 314-381-0928
  • Fax: 314-383-2873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateMO

VIII. Authorized Official

Name: MS. GELIS DEON HARRIS
Title or Position: ADMINISTRATOR
Credential:
Phone: 314-898-6916