- Enrollment id
- O20040810000207
- Enrollment state
- CA
- Provider type code
- 00-18
- Provider type text
- PART A PROVIDER - SKILLED NURSING FACILITY
- Npi
- 1609874163
- Multiple npi flag
- N
- Ccn
- 056048
- Associate id
- 9032181128
- Organization name
- COVENANT CARE CAPITOLA, LLC
- Doing business as name
- PACIFIC COAST MANOR
- Incorporation date
- 2003-05-21
- Incorporation state
- CA
- Organization type structure
- LLC
- Proprietary nonprofit
- P
- Nursing home provider name
- PACIFIC COAST MANOR
- Affiliation entity name
- COVENANT CARE
- Affiliation entity id
- 166
- Address line 1
- 1935 WHARF RD
- City
- CAPITOLA
- State
- CA
- Zip code
- 950102606