NPIMap

Organization Active NPI

Covenant Community Care, Inc.

Doing business as Moross Health Center

  • Federally Qualified Health Center (FQHC)
  • Detroit, MI
National Provider Identifier
1689925075
Registry record updated Apr 10, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
COVENANT COMMUNITY CARE, INC.
Doing business as
Moross Health Center
Practice address
20901 Moross Rd
Detroit, MI 48236-2058
Phone
(313) 626-2600
Fax
(313) 626-2605
NPI assigned
Sep 25, 2012
Last updated
Apr 10, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 10, 2023

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

Authorized official

Name
Anna Griebel Chavez
Title
Cfo
Phone
(313) 554-0485

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

20901 Moross Rd
Detroit, MI 48236-2058

Mailing address

559 W Grand Blvd
Detroit, MI 48216-2200
Phone (313) 554-0485

Other names 1

  • Moross Health Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20130321000197 MI Part A Provider - Federally Qualified Health Center (FQHC) 1254393549 Practice locations: Detroit, MI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1689925075. Details of each certification follow.

Federally qualified health center certification: CCN 231007

Legal name
COVENANT COMMUNITY CARE, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 21, 2001
Last certification
Mar 21, 2001
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Apr 20, 2000 in MI
Enrollment address
20901 Moross Rd
Detroit, MI 48236-2058

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Covenant Community Care Inc5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 13

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Joslyn Pettway Individual Corporate OfficerCeo Sep 28, 2019
W-2 Managing EmployeeCeo Sep 28, 2019
Mark Lubienski Individual Corporate DirectorBoard Treasurer Feb 1, 2017
Mitzi Cardona Individual Corporate DirectorBoard Member Aug 8, 2018
Julia Smith Individual Corporate DirectorBoard President Aug 1, 2022
Catherine a Wenz Individual Corporate DirectorBoard Member Aug 1, 2022
Prince Williams Individual Corporate DirectorBoard Member Dec 15, 2020
Semmeal Thomas Individual Corporate DirectorBoard Member May 6, 2013
Samuel Spruill Individual Corporate DirectorBoard Member Mar 6, 2013
Nancyann Turner Individual Corporate DirectorBoard Member Sep 21, 2021
William Krieg Individual Corporate DirectorBoard Member Jul 18, 2017
Anna Griebel Chavez Individual Corporate OfficerCfo Jul 11, 2016
W-2 Managing EmployeeCfo Jul 11, 2016
Ester Gallegos Individual Corporate DirectorBoard Member Jul 13, 2021
Graciela Villalobos Individual Corporate DirectorBoard Member Jan 1, 2007

Practitioners & affiliated clinicians

Practitioners 17

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 17

NPI Registry JSON

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

{
    "created_epoch": "1348531200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1681084800000",
    "number": "1689925075",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "559 W GRAND BLVD",
            "city": "DETROIT",
            "state": "MI",
            "postal_code": "482162200",
            "telephone_number": "313-554-0485",
            "fax_number": "313-228-0283"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "20901 MOROSS RD",
            "city": "DETROIT",
            "state": "MI",
            "postal_code": "482362058",
            "telephone_number": "313-626-2600",
            "fax_number": "313-626-2605"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COVENANT COMMUNITY CARE, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-09-25",
        "last_updated": "2023-04-10",
        "certification_date": "2023-04-10",
        "status": "A",
        "authorized_official_last_name": "CHAVEZ",
        "authorized_official_first_name": "ANNA",
        "authorized_official_middle_name": "GRIEBEL",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "313-554-0485"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Moross Health Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Moross Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Detroit, MI

Sources for this page

Verify at the official NPI Registry.