Provider Demographics
NPI:1194880690
Name:COVENANT HOSPICE INC
Entity type:Organization
Organization Name:COVENANT HOSPICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:
Authorized Official - Last Name:CLENEAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-433-2155
Mailing Address - Street 1:5041 N 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-8916
Mailing Address - Country:US
Mailing Address - Phone:850-433-2155
Mailing Address - Fax:850-202-5819
Practice Address - Street 1:3383 S FERDON BLVD # B-5
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-8484
Practice Address - Country:US
Practice Address - Phone:850-682-3628
Practice Address - Fax:850-682-8434
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COVENANT HOSPICE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-26
Last Update Date:2021-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5025095251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL087517100Medicaid
FLU20OtherBLUE CROSS BLUE SHIELD
FL087517100Medicaid
FLU20OtherBLUE CROSS BLUE SHIELD