Provider Demographics
NPI:1548878267
Name:COVENANT MEDICAL CENTER
Entity type:Organization
Organization Name:COVENANT MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR-REGULATORY & ENROLLMENT GOV PRG
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOEDEFELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-212-6354
Mailing Address - Street 1:PO BOX 677044
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-7044
Mailing Address - Country:US
Mailing Address - Phone:806-725-0314
Mailing Address - Fax:
Practice Address - Street 1:3615 19TH
Practice Address - Street 2:LIFESTYLE CENTRE-EAST PARKING GARAGE
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410
Practice Address - Country:US
Practice Address - Phone:806-725-0314
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COVENANT MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-07-20
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0404XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Cardiac Facilities