MEDICARE: COVENANT CARE CAPITOLA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	070000039	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609874163
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COVENANT CARE CAPITOLA, LLC

Provider Business Mailing Address
First Line	:	1935 WHARF RD
Second Line	:
City	:	CAPITOLA
State	:	CA
Zip	:	95010-2606
Country	:	US
Telephone Number	:	831-476-0770
Fax Number	:	831-476-0737

Provider Business Practice Location Address
First Line	:	1935 WHARF RD
Second Line	:
City	:	CAPITOLA
State	:	CA
Zip	:	95010-2606
Country	:	US
Telephone Number	:	831-476-0770
Fax Number	:	831-476-0737

Authorized Official
Title or Position	:	DIRECTOR OF REIMBURSEMENT
Name	:	CAROL A SPARKS
Credential	:
Telephone Number	:	949-349-1200

Provider Enumeration Date	:	07/08/2005
Last Update Date	:	07/24/2008

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