Provider Demographics
NPI:1891783577
Name:COVENANT CARE CALIFORNIA, LLC
Entity Type:Organization
Organization Name:COVENANT CARE CALIFORNIA, LLC
Other - Org Name:SHORELINE CARE 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:A
Authorized Official - Last Name:SPARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-349-1200
Mailing Address - Street 1:5225 S J ST
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93033-8320
Mailing Address - Country:US
Mailing Address - Phone:805-488-3696
Mailing Address - Fax:805-986-2524
Practice Address - Street 1:5225 S J ST
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93033-8320
Practice Address - Country:US
Practice Address - Phone:805-488-3696
Practice Address - Fax:805-986-2524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-07
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT18612IMedicaid
CAZZT18612IMedicaid