=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932537065
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COVENANT FAMILY CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2013
-----------------------------------------------------
Last Update Date | 10/29/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2838 JEFF RD SUITE D
-----------------------------------------------------
City | HARVEST
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35749-8646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-425-8004
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2838 JEFF RD SUITE D
-----------------------------------------------------
City | HARVEST
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35749-8646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-425-8004
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | DR. CYNTHIA BENITA BOOKER-GRADDICK
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 615-477-3364
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 1025
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------