MEDICARE: COVENANT CARE OF JACKSONVILLE 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	314000000X	Skilled Nursing Facility	0047852	IL
2	313M00000X	Nursing Facility/Intermediate Care Facility	1764855	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396811550
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COVENANT CARE OF JACKSONVILLE LLC

Provider Business Mailing Address
First Line	:	1200 MOUNTAIN CREEK ROAD
Second Line	:	SUITE 350
City	:	CHATTANOOGA
State	:	TN
Zip	:	37405-6103
Country	:	US
Telephone Number	:	423-870-3153
Fax Number	:	423-870-3196

Provider Business Practice Location Address
First Line	:	1500 WEST WALNUT STREET
Second Line	:
City	:	JACKSONVILLE
State	:	IL
Zip	:	62650-1134
Country	:	US
Telephone Number	:	217-245-4183
Fax Number	:	217-243-2915

Authorized Official
Title or Position	:	MANAGER
Name	:	GARY L POTTS
Credential	:
Telephone Number	:	423-870-3153

Provider Enumeration Date	:	11/28/2006
Last Update Date	:	07/19/2007

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