Provider Demographics
NPI:1104825520
Name:ENSIGN MONTGOMERY LLC
Entity Type:Organization
Organization Name:ENSIGN MONTGOMERY LLC
Other - Org Name:PARK VIEW POST ACUTE
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 1:3751 MONTGOMERY DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-5214
Mailing Address - Country:US
Mailing Address - Phone:707-525-1250
Mailing Address - Fax:707-525-1080
Practice Address - Street 1:3751 MONTGOMERY DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-5214
Practice Address - Country:US
Practice Address - Phone:707-525-1250
Practice Address - Fax:707-525-1080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-18
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA010000062314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR06411IMedicaid
CA056411Medicare Oscar/Certification