Healthcare Provider Details

I. General information

NPI: 1780672428
Provider Name (Legal Business Name): COVENANT CARE LONG BEACH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 VIRGINIA ROAD
LONG BEACH CA
90807-2627
US

IV. Provider business mailing address

120 VANTIS DR STE 200
ALISO VIEJO CA
92656-2677
US

V. Phone/Fax

Practice location:
  • Phone: 562-426-0394
  • Fax: 562-424-1529
Mailing address:
  • Phone: 949-349-1200
  • Fax: 949-349-1122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number940000049
License Number StateCA

VIII. Authorized Official

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