Provider Demographics
NPI:1194910679
Name:COVENANT COMM. DEV. CORP.
Entity type:Organization
Organization Name:COVENANT COMM. DEV. CORP.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:ALMA
Authorized Official - Middle Name:CORLISS
Authorized Official - Last Name:VINCENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-695-0684
Mailing Address - Street 1:1217 REV S HOWARD WOODSON JR WAY
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08638-4015
Mailing Address - Country:US
Mailing Address - Phone:609-695-0684
Mailing Address - Fax:609-396-1198
Practice Address - Street 1:1217 REV S HOWARD WOODSON JR WAY
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08638-4015
Practice Address - Country:US
Practice Address - Phone:609-695-0684
Practice Address - Fax:609-396-1198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0022101Medicaid