Healthcare Provider Details

I. General information

NPI: 1396986436
Provider Name (Legal Business Name): COVENANT CARE LODI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2009
Last Update Date: 02/24/2023
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N CHURCH ST
LODI CA
95240-1282
US

IV. Provider business mailing address

900 N CHURCH ST
LODI CA
95240-1282
US

V. Phone/Fax

Practice location:
  • Phone: 765-525-4371
  • Fax: 765-525-4246
Mailing address:
  • Phone: 765-525-4371
  • Fax: 765-525-4246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number100000220
License Number StateCA

VIII. Authorized Official

Name: CAROL SPARKS
Title or Position: DIRECTOR OF REIMBURSEMENT
Credential:
Phone: 949-349-1200