MEDICARE: COVENANT VILLAGE OPCO 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

General Provider Information

NPI Number	:	1902694722
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COVENANT VILLAGE OPCO LLC

Provider Business Mailing Address
First Line	:	5910 LANDERBROOK DR STE 150
Second Line	:
City	:	MAYFIELD HEIGHTS
State	:	OH
Zip	:	44124-6506
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3210 W FORK RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45211-1948
Country	:	US
Telephone Number	:	330-620-7828
Fax Number	:

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	JEFFREY DEGYANSKY
Credential	:
Telephone Number	:	330-620-7828

Provider Enumeration Date	:	04/30/2025
Last Update Date	:	12/04/2025

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