Organization
COVENANT CARE OF JACKSONVILLE LLC
Active
Other names
Modern Care Convalescent and Nursing Home
Organization subpart
No
Provider details
NPI number
Authorized official
GARY L POTTS (MANAGER)
(423) 870-3153
Entity
Organization
Contact information
Practice address
1500 WEST WALNUT STREET, JACKSONVILLE, IL 62650-1134
(217) 245-4183
(217) 243-2915
Mailing address
1200 MOUNTAIN CREEK ROAD, SUITE 350, CHATTANOOGA, TN 37405-6103
(423) 870-3153
(423) 870-3196
Taxonomy
Speciality
Code
Description
License number
State
313M00000X
Nursing Facility/Intermediate Care Facility
Primary
1764855
IL
314000000X
Skilled Nursing Facility
0047852
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0036301
—
IL
Enumeration date
11/28/2006
Last updated
07/19/2007
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