Healthcare Provider Details

I. General information

NPI: 1649375403
Provider Name (Legal Business Name): COVENANT LIVING WEST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 07/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 KEMPTON ST
SPRING VALLEY CA
91977-5810
US

IV. Provider business mailing address

325 KEMPTON ST
SPRING VALLEY CA
91977-5810
US

V. Phone/Fax

Practice location:
  • Phone: 619-479-4790
  • Fax: 619-479-2337
Mailing address:
  • Phone: 619-479-4790
  • Fax: 619-479-2337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number090000080
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateCA

VIII. Authorized Official

Name: ELIZABETH MALZAHN
Title or Position: VICE PRESIDENT OF HEALTH SERVICES
Credential:
Phone: 773-878-4430