Healthcare Provider Details

I. General information

NPI: 1043671704
Provider Name (Legal Business Name): THE COVINGTON'S COVE ASSISTED LIVING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2016
Last Update Date: 03/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

192 MARY MAGDALENE CHURCH RD
HATTIESBURG MS
39401
US

IV. Provider business mailing address

510 MAPLE DR
PETAL MS
39465-6816
US

V. Phone/Fax

Practice location:
  • Phone: 601-310-8014
  • Fax:
Mailing address:
  • Phone: 601-310-8014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State

VIII. Authorized Official

Name: MR. TRAVIS MONTEZ DELOACH
Title or Position: OWNER
Credential: RN
Phone: 601-310-8014