Provider Demographics
NPI:1255420295
Name:COVENANT HEALTH CARE CENTER, INC
Entity type:Organization
Organization Name:COVENANT HEALTH CARE CENTER, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE VICE PRESIDENT OF HEALTH
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MALZAHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-878-4430
Mailing Address - Street 1:2155 PFINGSTEN ROAD
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-5900
Mailing Address - Country:US
Mailing Address - Phone:847-480-6380
Mailing Address - Fax:847-480-7666
Practice Address - Street 1:2155 PFINGSTEN ROAD
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-5900
Practice Address - Country:US
Practice Address - Phone:847-480-6380
Practice Address - Fax:847-480-7666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0033779314000000X
IL314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL145527Medicare Oscar/Certification
IL145527Medicare UPIN