Provider Demographics
NPI:1104690197
Name:COVENANT COVE CARE LLC
Entity type:Organization
Organization Name:COVENANT COVE CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGEANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:STOKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-647-7546
Mailing Address - Street 1:101 KIRK AVE APT C7
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-2880
Mailing Address - Country:US
Mailing Address - Phone:662-647-7546
Mailing Address - Fax:
Practice Address - Street 1:101 KIRK AVE APT C7
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-2880
Practice Address - Country:US
Practice Address - Phone:662-647-7546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-09
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty
No310400000XNursing & Custodial Care FacilitiesAssisted Living FacilityGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1033983184Medicaid