Provider Demographics
NPI:1750536322
Name:COVENANT CARE CARSON, LLC
Entity type:Organization
Organization Name:COVENANT CARE CARSON, 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 1:2898 US HIGHWAY 50 E
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89701-2811
Mailing Address - Country:US
Mailing Address - Phone:775-882-3301
Mailing Address - Fax:775-883-9468
Practice Address - Street 1:2898 US HIGHWAY 50 E
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89701-2811
Practice Address - Country:US
Practice Address - Phone:775-882-3301
Practice Address - Fax:775-883-9468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-24
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1175SNF-14314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV18/19-13842Medicaid
295023Medicare Oscar/Certification