Provider Demographics
NPI:1831231877
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 1:8170 MURRAY AVENUE
Mailing Address - Street 2:
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-4605
Mailing Address - Country:US
Mailing Address - Phone:408-842-9311
Mailing Address - Fax:408-842-5439
Practice Address - Street 1:8170 MURRAY AVENUE
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-4605
Practice Address - Country:US
Practice Address - Phone:408-842-9311
Practice Address - Fax:408-842-5439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA070000035314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA206430760OtherOSHPD
CAZZR05797IMedicaid
CAZZR05797IMedicaid