Healthcare Provider Details

I. General information

NPI: 1104825520
Provider Name (Legal Business Name): ENSIGN MONTGOMERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 02/17/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3751 MONTGOMERY DR
SANTA ROSA CA
95405-5214
US

IV. Provider business mailing address

3751 MONTGOMERY DR
SANTA ROSA CA
95405-5214
US

V. Phone/Fax

Practice location:
  • Phone: 707-525-1250
  • Fax: 707-525-1080
Mailing address:
  • Phone: 707-525-1250
  • Fax: 707-525-1080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number010000062
License Number StateCA

VIII. Authorized Official

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