Healthcare Provider Details

I. General information

NPI: 1871594614
Provider Name (Legal Business Name): ENSIGN SONOMA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 02/17/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 BROADWAY
SONOMA CA
95476-7500
US

IV. Provider business mailing address

1250 BROADWAY
SONOMA CA
95476-7500
US

V. Phone/Fax

Practice location:
  • Phone: 707-938-8406
  • Fax: 707-938-4400
Mailing address:
  • Phone: 707-938-8406
  • Fax: 707-938-4400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number010000158
License Number StateCA

VIII. Authorized Official

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