Healthcare Provider Details

I. General information

NPI: 1871822825
Provider Name (Legal Business Name): COVENANT VILLAGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2009
Last Update Date: 12/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1351 ROBINWOOD RD
GASTONIA NC
28054-1693
US

IV. Provider business mailing address

1351 ROBINWOOD RD
GASTONIA NC
28054-1693
US

V. Phone/Fax

Practice location:
  • Phone: 704-867-2319
  • Fax: 704-867-4442
Mailing address:
  • Phone: 704-867-2319
  • Fax: 704-867-4442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: JUDY HOLCOMB
Title or Position: DIRECTOR OF NURSING
Credential: RN
Phone: 704-867-2319