1235367913 NPI number — COVENANT CARE COURTYARD, LLC

Table of content: (NPI 1235367913)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235367913 NPI number — COVENANT CARE COURTYARD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COVENANT CARE COURTYARD, 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:
1235367913
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1850 E 8TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAVIS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95616-2502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-756-1800
Provider Business Mailing Address Fax Number:
530-756-1859

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1850 E 8TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAVIS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95616-2502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-756-1800
Provider Business Practice Location Address Fax Number:
530-756-1859
Provider Enumeration Date:
07/01/2009

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ZZR05992I , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com