Basic Information
| Provider Information | |||||||||
| NPI: | 1962150037 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COVENANT CARE CALIFORNIA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 VANTIS DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | ALISO VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926562677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493491200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3620 DALE RD STE A | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953560598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095211798 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2022 | ||||||||
| LastUpdateDate: | 03/16/2022 | ||||||||
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| AuthorizedOfficialLastName: | SPARKS | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 9493491200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 507000307 | 01 | CA | DEPARTMENT OF SOCIAL SERVICES | OTHER |