NPIMap

Organization Active NPI

Covenant Community Care, Inc.

  • Federally Qualified Health Center (FQHC)
  • Detroit, MI
National Provider Identifier
1720134943
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.
Practice address
5716 Michigan Ave
Detroit, MI 48210-3039
Phone
(313) 554-1095
NPI assigned
Jan 28, 2007
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 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 4704195855 MI
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

5716 Michigan Ave
Detroit, MI 48210-3039

Mailing address

559 W Grand Blvd
Detroit, MI 48216-2200
Phone (313) 554-1095

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
O20041029000105 MI Part B Supplier - Clinic/Group Practice 1254393549 Receives reassigned benefits from 23 practitioners
Practice locations: Detroit, MI
O20080207000047 MI Part A Provider - Federally Qualified Health Center (FQHC) 1254393549 Practice locations: Detroit, MI
O20080326000806 MI Part A Provider - Federally Qualified Health Center (FQHC) 1254393549 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Detroit, MI

NPI to CCN mapping 2

The Medicare certification numbers (CCNs) connected to NPI 1720134943. Details of each certification follow.

Federally qualified health center certification: CCN 231925

Legal name
COVENANT COMMUNITY CARE, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 25, 2008
Last certification
Mar 25, 2008
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Apr 20, 2000 in MI
Enrollment address
5716 Michigan Ave
Detroit, MI 48210-3039

Federally qualified health center certification: CCN 231928

Legal name
COVENANT COMMUNITY CARE, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 19, 2008
Last certification
May 19, 2008
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Apr 20, 2000 in MI
Enrollment address
1700 Waterman St
Detroit, MI 48209-2022

Other NPIs with the same Medicare PAC ID 3

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

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Locations

17625 Joy Rd
Detroit, MI 48228
Phone (313) 446-8800

32932 Warren Rd
Westland, MI 48185
Phone (734) 298-0203

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 Vice President Aug 8, 2018
Corporate DirectorBoard Vice-Present Aug 8, 2018
Julia Smith Individual Corporate DirectorBoard President Aug 1, 2022
Corporate DirectorBoard President May 15, 2018
Catherine a Wenz Individual Corporate DirectorBoard Member Aug 1, 2022
Corporate DirectorBoard Secretary 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
Elizabeth Pitts Individual Corporate DirectorBoard Member Mar 21, 2023
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 May 21, 2019
Corporate DirectorBoard Member Jan 1, 2007

Practitioners & affiliated clinicians

Practitioners 23

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 23

NPI Registry JSON

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

{
    "created_epoch": "1169942400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1681084800000",
    "number": "1720134943",
    "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": "313-554-1095"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5716 MICHIGAN AVE",
            "city": "DETROIT",
            "state": "MI",
            "postal_code": "482103039",
            "telephone_number": "313-554-1095"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COVENANT COMMUNITY CARE, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-28",
        "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": "MI",
            "license": "4704195855",
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Detroit, MI

Sources for this page

Verify at the official NPI Registry.