Provider Demographics
NPI:1043345812
Name:COVENANT CARE CALIFORNIA, LLC
Entity Type:Organization
Organization Name:COVENANT CARE CALIFORNIA, LLC
Other - Org Name:LOS ALTOS SUB-ACUTE & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF REIMBURSMENT
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 1:809 FREMONT AVENUE
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94024-5617
Mailing Address - Country:US
Mailing Address - Phone:650-941-5255
Mailing Address - Fax:650-941-2822
Practice Address - Street 1:809 FREMONT AVENUE
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94024-5617
Practice Address - Country:US
Practice Address - Phone:650-941-5255
Practice Address - Fax:650-941-2822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA220000403314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR06116HMedicaid
CA206430721OtherOSHPD
CAZZR06116HMedicaid