Healthcare Provider Details

I. General information

NPI: 1295448967
Provider Name (Legal Business Name): DEERGRASS HEALTHCARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2022
Last Update Date: 12/27/2022
Certification Date: 12/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 S FAIRMONT AVE
LODI CA
95240-5131
US

IV. Provider business mailing address

950 S FAIRMONT AVE
LODI CA
95240-5131
US

V. Phone/Fax

Practice location:
  • Phone: 209-368-0693
  • Fax:
Mailing address:
  • Phone: 209-368-0693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: SOON BURNAM
Title or Position: TREASURER
Credential:
Phone: 949-540-1249