NPIMap

Organization Active NPI

Deergrass Healthcare, Inc.

Doing business as Fairmont Rehabilitation Hospital

  • Skilled Nursing Facility
  • Lodi, CA
National Provider Identifier
1295448967
Registry record updated Dec 27, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
Legal business name
DEERGRASS HEALTHCARE, INC.
Doing business as
Fairmont Rehabilitation Hospital
Practice address
950 S Fairmont Ave
Lodi, CA 95240-5131
Phone
(209) 368-0693
NPI assigned
Dec 27, 2022
Last updated
Dec 27, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 27, 2022

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

Authorized official

Name
Soon Burnam
Title
Treasurer
Phone
(949) 540-1249

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X NU Primary

Addresses

Primary practice location

950 S Fairmont Ave
Lodi, CA 95240-5131

Mailing address

950 S Fairmont Ave
Lodi, CA 95240-5131
Phone (209) 368-0693

Other names 1

  • Fairmont Rehabilitation Hospital Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL https://199.119.81.30:8291/Gateway/DocumentSubmission/2_0NhinService/XDRReesponse_Service Other eSolutions Inc.

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20230306002686 CA Part A Provider - Skilled Nursing Facility 7517330913 Practice locations: Lodi, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1295448967. Details of each certification follow.

Skilled nursing facility certification: CCN 055242

Legal name
DEERGRASS HEALTHCARE, INC.
Doing business as
FAIRMONT REHABILITATION HOSPITAL
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Jan 1, 1967
Last certification
Jan 16, 2025
Beds
59
Ownership / control type
Corporation
Most recent change of ownership
Feb 1, 2023
Organization structure
CorporationProprietary
Incorporated
Nov 8, 2022 in NV
Enrollment address
950 S Fairmont Ave
Lodi, CA 95240-5131
Nursing home name
FAIRMONT REHABILITATION HOSPITAL
Affiliated entity
THE ENSIGN GROUP

Care Compare: Nursing home

Medicare Care Compare
Listed as
Fairmont Rehabilitation HospitalCCN 055242 · All quality measures
Overall star rating
4 of 5
Health inspections
4 of 5
Staffing
4 of 5
Quality measures
4 of 5
Type
Medicare and Medicaid
Ownership
For profit - Corporation
Certified
Jan 1, 1967
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
5954.6 residents per day on average
Chain
The Ensign Group342 facilities in the chain

Processed by Care Compare on Aug 1, 2026.

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 11

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

NameRoleSinceShare
Shiraz Buhari Individual Operational/Managerial Control Feb 1, 2023
Managing Control - Governing BodyMedical Director Feb 1, 2023
Adp of the SNF Feb 1, 2023
Flagstone Healthcare North LLC Organization, San Juan Capistrano, CA LLC 5% Or Greater Direct Ownership Interest Nov 8, 2022 100%
Barry Port Individual Managing Control - Governing BodySole Manager Jul 26, 2018
The Ensign Group Inc Organization, San Juan Capistrano, CA Corporation 5% Or Greater Indirect Ownership Interest Feb 1, 2023 100%
Ensign Services Inc Organization, San Juan Capistrano, CA Corporation Adp of the SNF Oct 31, 2025
Adam Willits Individual Corporate DirectorDirector Deergrass Healthcare, Inc. Feb 1, 2023
Ami Sato Individual Corporate OfficerTreasurer Deergrass Healthcare, Inc Sep 9, 2024
Chad Keetch Individual Corporate OfficerSecretary Ensign Services, Inc. Mar 1, 2011
Cory R Monette Individual Corporate OfficerPresident Deergrass Healthcare, Inc Feb 1, 2023
Soon Burnam Individual Corporate OfficerSecretary Deergrass Healthcare, Inc Nov 8, 2022
Randy Tu Individual Operational/Managerial ControlAdministrator Feb 1, 2023
Managing Control - Governing BodyAdministrator Feb 1, 2023
Adp of the SNF Feb 1, 2023

Owners & managing parties with NPI records 1

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

  • Shiraz Buhari, MD
    • Family Medicine Physician
    • Stockton, CA
    • NPI 1700855418

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

    CMS ownership

Facilities with the same owner 12

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

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

Affiliated clinicians 6

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": "1672099200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1672099200000",
    "number": "1295448967",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "950 S FAIRMONT AVE",
            "city": "LODI",
            "state": "CA",
            "postal_code": "952405131",
            "telephone_number": "209-368-0693"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "950 S FAIRMONT AVE",
            "city": "LODI",
            "state": "CA",
            "postal_code": "952405131",
            "telephone_number": "209-368-0693"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DEERGRASS HEALTHCARE, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-12-27",
        "last_updated": "2022-12-27",
        "certification_date": "2022-12-27",
        "status": "A",
        "authorized_official_last_name": "BURNAM",
        "authorized_official_first_name": "SOON",
        "authorized_official_title_or_position": "TREASURER",
        "authorized_official_telephone_number": "949-540-1249"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://199.119.81.30:8291/Gateway/DocumentSubmission/2_0NhinService/XDRReesponse_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.1066.1",
            "affiliationName": "eSolutions Inc.",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "esMD eMDR",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "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": "Fairmont Rehabilitation Hospital",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lodi, CA

Sources for this page

Verify at the official NPI Registry.