Basic Information
| Provider Information | |||||||||
| NPI: | 1609941004 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEW COVENANT CARE OF DINUBA, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | NEW COVENANT CARE OF DINUBA, INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1730 S COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | DINUBA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936182812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5595913300 | ||||||||
| FaxNumber: | 5595910705 | ||||||||
| Practice Location | |||||||||
| Address1: | 1730 S COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | DINUBA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936182812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5595913300 | ||||||||
| FaxNumber: | 5595910705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 12/19/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KREH | ||||||||
| AuthorizedOfficialFirstName: | LAWRENCE (LARRY) | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 9259377400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 120000578 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | ZZT05448H | 05 | CA | MEDICAID |