=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780761478
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COVENANT CARE CENTER OF QUANAH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 07/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1106 W 14TH ST
-----------------------------------------------------
City | QUANAH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79252-6300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-663-2869
-----------------------------------------------------
Fax | 940-663-6429
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1106 W 14TH ST
-----------------------------------------------------
City | QUANAH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79252-6300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-663-2869
-----------------------------------------------------
Fax | 940-663-6429
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. RONALD SANBORN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 832-717-5519
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 118688
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------