Healthcare Provider Details

I. General information

NPI: 1437291929
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

3620 DALE RD SUITE B
MODESTO CA
95356-0598
US

IV. Provider business mailing address

3620 DALE RD SUITE B
MODESTO CA
95356-0598
US

V. Phone/Fax

Practice location:
  • Phone: 209-521-2094
  • Fax: 209-521-6180
Mailing address:
  • Phone: 209-521-2094
  • Fax: 209-521-6180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number100000366
License Number StateCA

VIII. Authorized Official

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