Basic Information
| Provider Information | |||||||||
| NPI: | 1619966207 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COVENANT HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | COVENANT HEALTH SYSTEM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4709 66TH ST | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794144841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067258400 | ||||||||
| FaxNumber: | 8067258463 | ||||||||
| Practice Location | |||||||||
| Address1: | 1308 TEASLEY LN | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762057946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9403821011 | ||||||||
| FaxNumber: | 9403833435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2005 | ||||||||
| LastUpdateDate: | 08/04/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MATANI | ||||||||
| AuthorizedOfficialFirstName: | SAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 8067258691 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 007008 | TX | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 012888601 | 05 | TX | MEDICAID | 024564901 | 05 | TX | MEDICAID |