Provider Demographics
NPI:1396986436
Name:COVENANT CARE LODI, LLC
Entity type:Organization
Organization Name:COVENANT CARE LODI, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF REIMBURSEMENT
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:SPARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-349-1200
Mailing Address - Street 1:900 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-1282
Mailing Address - Country:US
Mailing Address - Phone:765-525-4371
Mailing Address - Fax:765-525-4246
Practice Address - Street 1:900 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-1282
Practice Address - Country:US
Practice Address - Phone:765-525-4371
Practice Address - Fax:765-525-4246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-19
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100000220314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA555164Medicare Oscar/Certification