MEDICARE: COVENANT CARE LONG BEACH, INC.

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	940000049	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	:	1780672428
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COVENANT CARE LONG BEACH, INC.

Provider Business Mailing Address
First Line	:	120 VANTIS DR STE 200
Second Line	:
City	:	ALISO VIEJO
State	:	CA
Zip	:	92656-2677
Country	:	US
Telephone Number	:	949-349-1200
Fax Number	:	949-349-1122

Provider Business Practice Location Address
First Line	:	4010 VIRGINIA ROAD
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90807-2627
Country	:	US
Telephone Number	:	562-426-0394
Fax Number	:	562-424-1529

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

Provider Enumeration Date	:	10/06/2005
Last Update Date	:	12/10/2024

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