Healthcare Provider Details

I. General information

NPI: 1053453902
Provider Name (Legal Business Name): COVENANT CARE CALIFORNIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 02/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2725 PACIFIC AVENUE
LONG BEACH CA
90806-2612
US

IV. Provider business mailing address

2725 PACIFIC AVENUE
LONG BEACH CA
90806-2612
US

V. Phone/Fax

Practice location:
  • Phone: 562-427-7493
  • Fax: 562-424-1833
Mailing address:
  • Phone: 562-427-7493
  • Fax: 562-424-1833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number940000145
License Number StateCA

VIII. Authorized Official

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