Basic Information
| Provider Information | |||||||||
| NPI: | 1467728303 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COVENANT OPTIMIZED LIVING LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4910 FREDERICK AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645063246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162333700 | ||||||||
| FaxNumber: | 8162333754 | ||||||||
| Practice Location | |||||||||
| Address1: | 4910 FREDERICK AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645063246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162333700 | ||||||||
| FaxNumber: | 8162333754 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2012 | ||||||||
| LastUpdateDate: | 03/26/2012 | ||||||||
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| AuthorizedOfficialLastName: | HAYWOOD | ||||||||
| AuthorizedOfficialFirstName: | KARI | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8162333700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 112571 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.