=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659670412
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COVENANT PEDIATRICS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2011
-----------------------------------------------------
Last Update Date | 05/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 421 OLD RICEVILLE RD STE 2
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37303-3074
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-744-8755
-----------------------------------------------------
Fax | 423-744-8568
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 421 OLD RICEVILLE RD STE 2
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37303-3074
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-744-8755
-----------------------------------------------------
Fax | 423-744-8568
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS MANAGER
-----------------------------------------------------
Name | OMER BREEDEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 423-744-8755
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number | MD19704
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------