Provider Demographics
NPI:1528100013
Name:COVENANT CARE CALIFORNIA, LLC
Entity type:Organization
Organization Name:COVENANT CARE CALIFORNIA, 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 1:577 SOUTH PEACH AVENUE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-3952
Mailing Address - Country:US
Mailing Address - Phone:559-251-8463
Mailing Address - Fax:559-251-4465
Practice Address - Street 1:577 SOUTH PEACH AVENUE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727-3952
Practice Address - Country:US
Practice Address - Phone:559-251-8463
Practice Address - Fax:559-251-4465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA040000130314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR06207JMedicaid
CA206100772OtherOSHPD
CA056207Medicare Oscar/Certification