Provider Demographics
NPI:1639205925
Name:COVENANT CARE CALIFORNIA, LLC
Entity type:Organization
Organization Name:COVENANT CARE CALIFORNIA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:120 VANTIS DR STE 200
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-2677
Mailing Address - Country:US
Mailing Address - Phone:949-349-1222
Mailing Address - Fax:949-349-1122
Practice Address - Street 1:2435 WAGNER HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-1778
Practice Address - Country:US
Practice Address - Phone:209-477-5353
Practice Address - Fax:209-477-9959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA397000308310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARCF00025FMedicaid