Provider Demographics
NPI:1184021768
Name:COVENANT LIVING WEST
Entity Type:Organization
Organization Name:COVENANT LIVING WEST
Other - Org Name:BRANDEL MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NATIONAL DIRECTOR OF HEALTHCARE
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:MALZAHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-878-4430
Mailing Address - Street 1:5700 OLD ORCHARD RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-1036
Mailing Address - Country:US
Mailing Address - Phone:773-878-4430
Mailing Address - Fax:
Practice Address - Street 1:1801 N OLIVE AVE
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-2568
Practice Address - Country:US
Practice Address - Phone:209-667-5600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-26
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA055635314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1306281688OtherNPI
CA1306281688OtherNPI