Covenant Care of Jacksonville LLC

Primary specialty

Nursing Facility/Intermediate Care FacilityTaxonomy code 313M00000X

License

1764855 Issued in IL

Legal business name

COVENANT CARE OF JACKSONVILLE LLC

Doing business as

Modern Care Convalescent and Nursing Home

Practice address

1500 West Walnut Street
Jacksonville, IL 62650-1134

Phone

(217) 245-4183

Fax

(217) 243-2915

NPI assigned

Nov 28, 2006

Last updated

Jul 19, 2007By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Gary L Potts

Title

Manager

Phone

(423) 870-3153

Specialties & licenses 2

Addresses

Other identifiers 1

Other names 1

• Modern Care Convalescent and Nursing Home Doing business as

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1164672000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1184803200000",
    "number": "1396811550",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1200 MOUNTAIN CREEK ROAD",
            "address_2": "SUITE 350",
            "city": "CHATTANOOGA",
            "state": "TN",
            "postal_code": "374056103",
            "telephone_number": "423-870-3153",
            "fax_number": "423-870-3196"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1500 WEST WALNUT STREET",
            "city": "JACKSONVILLE",
            "state": "IL",
            "postal_code": "626501134",
            "telephone_number": "217-245-4183",
            "fax_number": "217-243-2915"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COVENANT CARE OF JACKSONVILLE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-28",
        "last_updated": "2007-07-19",
        "status": "A",
        "authorized_official_last_name": "POTTS",
        "authorized_official_first_name": "GARY",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "423-870-3153"
    },
    "taxonomies": [
        {
            "code": "313M00000X",
            "taxonomy_group": "",
            "desc": "Nursing Facility/Intermediate Care Facility",
            "state": "IL",
            "license": "1764855",
            "primary": true
        },
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "IL",
            "license": "0047852",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0036301",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Modern Care Convalescent and Nursing Home",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Community Living Options Inc (Lafayette Terrace)
• Community Living Options Inc (Douglas Terrace)
• David D Coultas, M.D.
• County of Morgan Health Dept
• Covenant Care Jacksonville, LLC (Jacksonville Skilled Nursing and Rehabilitation Center)
• Cpo Services, Inc (Comprehensive Prosthetics & Orthotics)
• Cara Marie Crain, FNP-C
• Rachel Elizabeth Cullen
• Abby L Cunningham, FNP
• Faraz Ahmad Khan Daha, MD

• Nursing Facility/Intermediate Care Facility in Jacksonville, IL
• Providers in Jacksonville, IL by specialty
• Nursing Facility/Intermediate Care Facility in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 19, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.