Provider Demographics
NPI:1215936430
Name:COVENANT HEALTHCARE, LLC
Entity type:Organization
Organization Name:COVENANT HEALTHCARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:P
Authorized Official - Last Name:DEIGNAN
Authorized Official - Suffix:
Authorized Official - Credentials:NHA, CPA
Authorized Official - Phone:715-552-1030
Mailing Address - Street 1:1405 TRUAX BLVD
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703-1474
Mailing Address - Country:US
Mailing Address - Phone:175-552-1030
Mailing Address - Fax:715-552-1033
Practice Address - Street 1:1405 TRUAX BLVD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703-1474
Practice Address - Country:US
Practice Address - Phone:175-552-1030
Practice Address - Fax:715-552-1033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3195314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3195Medicaid
WI20178200Medicaid
WI41480100Medicaid
WI20178200Medicaid