Healthcare Provider Details

I. General information

NPI: 1346382298
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

2124 57TH AVENUE
OAKLAND CA
94621-4322
US

IV. Provider business mailing address

2124 57TH AVENUE
OAKLAND CA
94621-4322
US

V. Phone/Fax

Practice location:
  • Phone: 510-261-2628
  • Fax: 510-261-5483
Mailing address:
  • Phone: 510-261-2628
  • Fax: 510-261-5483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number020000123
License Number StateCA

VIII. Authorized Official

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