Provider Demographics
NPI:1245225176
Name:ENSIGN CLOVERDALE LLC
Entity Type:Organization
Organization Name:ENSIGN CLOVERDALE LLC
Other - Org Name:CLOVERDALE HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:MS
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 1:300 CHERRY CREEK ROAD
Mailing Address - Street 2:
Mailing Address - City:CLOVERDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95425-3811
Mailing Address - Country:US
Mailing Address - Phone:707-894-5201
Mailing Address - Fax:707-894-9324
Practice Address - Street 1:300 CHERRY CREEK ROAD
Practice Address - Street 2:
Practice Address - City:CLOVERDALE
Practice Address - State:CA
Practice Address - Zip Code:95425-3811
Practice Address - Country:US
Practice Address - Phone:707-894-5201
Practice Address - Fax:707-894-9324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-16
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA010000157314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR05756IMedicaid
CA055756Medicare Oscar/Certification