MEDICARE: CLAYDELLE HEALTHCARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility		CA

General Provider Information

NPI Number	:	1073916987
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLAYDELLE HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	151 CLAYDELLE AVE
Second Line	:
City	:	EL CAJON
State	:	CA
Zip	:	92020-4505
Country	:	US
Telephone Number	:	619-448-0245
Fax Number	:	619-442-3631

Provider Business Practice Location Address
First Line	:	151 CLAYDELLE AVE
Second Line	:
City	:	EL CAJON
State	:	CA
Zip	:	92020-4505
Country	:	US
Telephone Number	:	619-448-0245
Fax Number	:	619-442-3631

Authorized Official
Title or Position	:	SECRETARY
Name	:	SOON BURNAM
Credential	:
Telephone Number	:	949-540-1249

Provider Enumeration Date	:	10/06/2014
Last Update Date	:	04/06/2026

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