Healthcare Provider Details

I. General information

NPI: 1164563276
Provider Name (Legal Business Name): COVENANT CARE CALIFORNIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 10/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 E. TUOLUMNE ROAD
TURLOCK CA
95382-1541
US

IV. Provider business mailing address

1111 E. TUOLUMNE ROAD
TURLOCK CA
95382-1541
US

V. Phone/Fax

Practice location:
  • Phone: 209-632-7577
  • Fax: 209-669-9067
Mailing address:
  • Phone: 209-632-7577
  • Fax: 209-669-9067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number030000261
License Number StateCA

VIII. Authorized Official

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