Provider Demographics
NPI:1023562865
Name:COVENANT HOSPICE, INC.
Entity type:Organization
Organization Name:COVENANT HOSPICE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:
Authorized Official - Last Name:CLENEAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-433-2155
Mailing Address - Street 1:5041 N. 12TH AVE.
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504
Mailing Address - Country:US
Mailing Address - Phone:850-433-2155
Mailing Address - Fax:
Practice Address - Street 1:6801 AIRPORT BLVD.
Practice Address - Street 2:MAIN TOWER, 11TH FLOOR NORTH
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608
Practice Address - Country:US
Practice Address - Phone:850-433-2155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COVENANT HOSPICE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-10
Last Update Date:2021-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RH0002X
FL5025095315D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes315D00000XNursing & Custodial Care FacilitiesHospice, InpatientGroup - Single Specialty
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL01-1577Medicare UPIN