Provider Demographics
NPI:1801938816
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 1:9289 BRANSTETTER PLACE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-1700
Mailing Address - Country:US
Mailing Address - Phone:209-477-5252
Mailing Address - Fax:209-474-0569
Practice Address - Street 1:9289 BRANSTETTER PLACE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-1700
Practice Address - Country:US
Practice Address - Phone:209-477-5252
Practice Address - Fax:209-474-0569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100000355314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA206394006OtherOSHPD
CALTC55332HMedicaid
CA206394006OtherOSHPD