Provider Demographics
NPI:1457486078
Name:COVENANT CARE LA JOLLA, LLC
Entity Type:Organization
Organization Name:COVENANT CARE LA JOLLA, LLC
Other - Org Name:LA JOLLA NURSING AND REHABILITATION 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 1:2552 TORREY PINES RD
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-3432
Mailing Address - Country:US
Mailing Address - Phone:858-453-5810
Mailing Address - Fax:858-452-4301
Practice Address - Street 1:2552 TORREY PINES RD
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-3432
Practice Address - Country:US
Practice Address - Phone:858-453-5810
Practice Address - Fax:858-452-4301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA080000098314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA206370779OtherOSHPD
CAZZT06017IMedicaid
CA056017Medicare Oscar/Certification