Healthcare Provider Details

I. General information

NPI: 1528362753
Provider Name (Legal Business Name): COVENANT WAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2011
Last Update Date: 01/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 FRANK PRESSLY DRIVE
DUE WEST SC
29639-0307
US

IV. Provider business mailing address

PO BOX 307
DUE WEST SC
29639-0307
US

V. Phone/Fax

Practice location:
  • Phone: 864-379-2570
  • Fax: 864-379-2570
Mailing address:
  • Phone: 864-379-2570
  • Fax: 864-379-2571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNCF-0775
License Number StateSC

VIII. Authorized Official

Name: MR. ROBERT PAUL PRIDMORE
Title or Position: CEO
Credential: NHA, CRCFA
Phone: 864-379-2570