Healthcare Provider Details

I. General information

NPI: 1245234897
Provider Name (Legal Business Name): COVENANT CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

344 W LINCOLN AVE
FALL CREEK WI
54742-9397
US

IV. Provider business mailing address

PO BOX 398
FALL CREEK WI
54742-0398
US

V. Phone/Fax

Practice location:
  • Phone: 715-877-2411
  • Fax: 715-877-2416
Mailing address:
  • Phone: 715-877-2411
  • Fax: 715-877-2416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2073
License Number StateWI

VIII. Authorized Official

Name: MR. JOHN CHARLES HALBLEIB
Title or Position: ADMINISTRATOR
Credential:
Phone: 715-877-2411