Provider Demographics
NPI:1346382298
Name:COVENANT CARE CALIFORNIA, LLC
Entity Type:Organization
Organization Name:COVENANT CARE CALIFORNIA, LLC
Other - Org Name:WILLOW TREE NURSING CENTER
Other - Org Type:Doing Business As
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 1:2124 57TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94621-4322
Mailing Address - Country:US
Mailing Address - Phone:510-261-2628
Mailing Address - Fax:510-261-5483
Practice Address - Street 1:2124 57TH AVENUE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94621-4322
Practice Address - Country:US
Practice Address - Phone:510-261-2628
Practice Address - Fax:510-261-5483
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
CA020000123314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR05876IMedicaid
CA206010995OtherOSHPD
CAZZR05876IMedicaid