MEDICARE: COVENANT CONNECTIONS HOME CARE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency		MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	23-7776	OTHER	MI	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1376687897	OTHER	MI	OMNICARE
2	IE911	OTHER	MI	BLUE CROSS/BLUE SHEILD

General Provider Information

NPI Number	:	1376687897
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COVENANT CONNECTIONS HOME CARE, LLC

Provider Business Mailing Address
First Line	:	18440 W MCNICHOLS RD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48219-4161
Country	:	US
Telephone Number	:	313-592-1517
Fax Number	:	313-592-1530

Provider Business Practice Location Address
First Line	:	18440 W MCNICHOLS RD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48219-4161
Country	:	US
Telephone Number	:	313-592-1517
Fax Number	:	313-592-1530

Authorized Official
Title or Position	:	CEO
Name	:	MS. BETTY JOYCE INGRAM
Credential	:	RN
Telephone Number	:	313-592-1517

Provider Enumeration Date	:	02/17/2007
Last Update Date	:	03/05/2012

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Directions to “COVENANT CONNECTIONS HOME CARE, LLC ” Practice Location

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