Provider Demographics
NPI:1679794143
Name:COVENANT HOME SERVICES
Entity type:Organization
Organization Name:COVENANT HOME SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF HEALTH SERVICES
Authorized Official - Prefix:MS
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 1:3755 E MAIN ST STE 165
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2409
Mailing Address - Country:US
Mailing Address - Phone:630-845-0680
Mailing Address - Fax:630-845-0685
Practice Address - Street 1:3755 EAST MAIN STREET
Practice Address - Street 2:SUITE 165
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174
Practice Address - Country:US
Practice Address - Phone:630-845-0680
Practice Address - Fax:630-845-0685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1011067251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9898OtherBLUE CROSS BLUE SHIELD
IL9898OtherBLUE CROSS BLUE SHIELD
IL147618Medicare Oscar/Certification
IL1011067Medicare PIN