=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942519558
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COVENANT COMMUNITY MEDICAL GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2010
-----------------------------------------------------
Last Update Date | 02/24/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3803 UNION AVE
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93305-2400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-321-9206
-----------------------------------------------------
Fax | 661-321-0932
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3803 UNION AVE
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93305-2400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-321-9206
-----------------------------------------------------
Fax | 661-321-0932
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. ARTNEY MICHELLE JACKSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 661-321-9206
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | G41041
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------