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General NPI Number Information
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NPI Number | 1831281609
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Entity Type | Organization
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Legal Business Name | COVENANT PLACE OF WAXAHACHIE
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Dates
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Enumeration Date | 09/29/2006
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Last Update Date | 03/08/2012
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Provider Practice Location Address
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Address Line | 401 SOLON RD
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City | WAXAHACHIE
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State | TX
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Zip | 75165-1328
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Country | US
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Telephone | 972-935-9363
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Fax | 972-923-3289
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Provider Business Mailing Address
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Address Line | 14160 DALLAS PKWY SUITE 300
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City | DALLAS
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State | TX
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Zip | 75254-4319
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Country | US
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Telephone | 972-770-5600
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Fax | 972-770-5666
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Authorized Official
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Title or Position | PRESIDENT & COO
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Name | KEITH JOHANNESSEN
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Credential |
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Telephone | 972-770-5600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 117586
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License Number State | TX
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