Provider Demographics
NPI:1073916987
Name:CLAYDELLE HEALTHCARE LLC
Entity Type:Organization
Organization Name:CLAYDELLE HEALTHCARE LLC
Other - Org Name:SOMERSET SUBACUTE AND CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:SOON
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-540-1249
Mailing Address - Street 1:151 CLAYDELLE AVE
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-4505
Mailing Address - Country:US
Mailing Address - Phone:619-448-0245
Mailing Address - Fax:619-442-3631
Practice Address - Street 1:151 CLAYDELLE AVE
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-4505
Practice Address - Country:US
Practice Address - Phone:619-448-0245
Practice Address - Fax:619-442-3631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-06
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA555871Medicare Oscar/Certification