Healthcare Provider Details

I. General information

NPI: 1184021768
Provider Name (Legal Business Name): COVENANT LIVING WEST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2014
Last Update Date: 07/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 N OLIVE AVE
TURLOCK CA
95382-2568
US

IV. Provider business mailing address

5700 OLD ORCHARD RD SUITE 100
SKOKIE IL
60077-1036
US

V. Phone/Fax

Practice location:
  • Phone: 209-667-5600
  • Fax:
Mailing address:
  • Phone: 773-878-4430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number055635
License Number StateCA

VIII. Authorized Official

Name: MRS. ELIZABETH A MALZAHN
Title or Position: NATIONAL DIRECTOR OF HEALTHCARE
Credential:
Phone: 773-878-4430