NPIMap

Organization Active NPI

Ensign Cloverdale LLC

Doing business as Cloverdale Healthcare Center

  • Skilled Nursing Facility
  • Cloverdale, CA
National Provider Identifier
1245225176
Registry record updated Feb 17, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
License
010000157 Issued in CA
Legal business name
ENSIGN CLOVERDALE LLC
Doing business as
Cloverdale Healthcare Center
Practice address
300 Cherry Creek Road
Cloverdale, CA 95425-3811
Phone
(707) 894-5201
Fax
(707) 894-9324
NPI assigned
Sep 16, 2005
Last updated
Feb 17, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 17, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ms. Soon Burnam
Title
Authorized Agent
Phone
(949) 540-1249

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X 010000157 CA Primary

Addresses

Primary practice location

300 Cherry Creek Road
Cloverdale, CA 95425-3811

Mailing address

300 Cherry Creek Road
Cloverdale, CA 95425-3811
Phone (707) 894-5201

Other identifiers 1

IdentifierTypeStateIssuer
ZZR05756IMedicaidCA

Other names 1

  • Cloverdale Healthcare Center Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL https://199.119.81.30:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRResponse_Service Other eSolutions Inc.

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120119000895 CA Part A Provider - Skilled Nursing Facility 2365619004 Practice locations: Cloverdale, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1245225176. Details of each certification follow.

Skilled nursing facility certification: CCN 055756

Legal name
ENSIGN CLOVERDALE LLC
Doing business as
CLOVERDALE HEALTHCARE CENTER
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Jul 16, 1974
Last certification
Jan 9, 2025
Beds
72
Ownership / control type
Limited Liability Corporation
Multi-facility organization
Ensign
Organization structure
LLCProprietary
Incorporated
Aug 30, 2001 in NV
Enrollment address
300 Cherry Creek Rd
Cloverdale, CA 95425-3811
Nursing home name
CLOVERDALE HEALTHCARE CENTER
Affiliated entity
THE ENSIGN GROUP

Care Compare: Nursing home

Medicare Care Compare
Listed as
Cloverdale Healthcare CenterCCN 055756 · All quality measures
Overall star rating
5 of 5
Health inspections
5 of 5
Staffing
3 of 5
Quality measures
5 of 5
Type
Medicare and Medicaid
Ownership
For profit - Limited Liability company
Certified
Jul 16, 1974
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
7255.8 residents per day on average
Chain
The Ensign Group342 facilities in the chain

Processed by Care Compare on Aug 1, 2026.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
05D0611944Cloverdale Healthcare Center300 Cherry Creek Rd, Cloverdale, CA 95425Certificate of waiverJun 28, 2027

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 10

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Flagstone Healthcare North LLC Organization, San Juan Capistrano, CA LLC 5% Or Greater Direct Ownership Interest Feb 1, 2006 100%
Red Barn Lakeside Holdings, LLC Organization, Post Falls, ID LLC Adp of the SNF Mar 1, 2019
The Ensign Group Inc Organization, San Juan Capistrano, CA Corporation 5% Or Greater Direct Ownership Interest Jan 30, 2006 100%
Ensign Services Inc Organization, San Juan Capistrano, CA Corporation Adp of the SNF Nov 17, 2003
Adam Willits Individual Corporate OfficerSole Manager Nov 15, 2025
Twomagnets LLC Organization, Covina, CA LLC Operational/Managerial Control Nov 15, 2001
Adp of the SNF Nov 15, 2001
Noel Serrano Individual Operational/Managerial Control May 1, 2021
Managing Control - Governing BodyMedical Director May 1, 2021
Adp of the SNF May 1, 2021
Chad Keetch Individual Corporate OfficerSecretary Ensign Services, Inc. Mar 1, 2011
Shawndee Gamble Individual Operational/Managerial Control Nov 15, 2001
Managing Control - Governing BodyAdministrator Nov 15, 2001
Adp of the SNF Nov 15, 2001
Soon Burnam Individual Corporate OfficerSecretary Ensign Cloverdale LLC Feb 1, 2006

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

  • Noel Serrano, M.D.
    • Internal Medicine Physician
    • Oakland, CA
    • NPI 1700925211

    Adp of the SNF, Managing Control - Governing Body, Operational/Managerial Control

    CMS ownership

Facilities with the same owner 42

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 42

Practitioners & affiliated clinicians

Affiliated clinicians 1

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1126828800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1613520000000",
    "number": "1245225176",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "300 CHERRY CREEK ROAD",
            "city": "CLOVERDALE",
            "state": "CA",
            "postal_code": "954253811",
            "telephone_number": "707-894-5201",
            "fax_number": "707-894-9324"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "300 CHERRY CREEK ROAD",
            "city": "CLOVERDALE",
            "state": "CA",
            "postal_code": "954253811",
            "telephone_number": "707-894-5201",
            "fax_number": "707-894-9324"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ENSIGN CLOVERDALE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-09-16",
        "last_updated": "2021-02-17",
        "certification_date": "2021-02-17",
        "status": "A",
        "authorized_official_last_name": "BURNAM",
        "authorized_official_first_name": "SOON",
        "authorized_official_title_or_position": "AUTHORIZED AGENT",
        "authorized_official_telephone_number": "949-540-1249",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "CA",
            "license": "010000157",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "ZZR05756I",
            "state": "CA"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://199.119.81.30:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRResponse_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113833.3.1066.1",
            "affiliationName": "eSolutions Inc.",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "contentType": "CSV",
            "contentTypeDescription": "CSV",
            "address_1": "8215 W 108th Ter",
            "city": "Overland Park",
            "state": "KS",
            "country_code": "US",
            "postal_code": "662101661",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Cloverdale Healthcare Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Cloverdale Healthcare Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Cloverdale, CA

Sources for this page

Verify at the official NPI Registry.