1124154422 NPI number — COVENANT CARE MORGAN HILL, LLC

Table of content: (NPI 1124154422)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124154422 NPI number — COVENANT CARE MORGAN HILL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COVENANT CARE MORGAN HILL, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124154422
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
370 NOBLE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORGAN HILL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95037-4134
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-779-7346
Provider Business Mailing Address Fax Number:
408-779-9435

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
370 NOBLE CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORGAN HILL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95037-4134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-779-7346
Provider Business Practice Location Address Fax Number:
408-779-9435
Provider Enumeration Date:
02/23/2007

Additional Information

			
		

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  070000040 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 206434001 . This is a "OSHPD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZR06037H , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".