Healthcare Provider Details

I. General information

NPI: 1750352191
Provider Name (Legal Business Name): BRASWELLS IVY RETREAT LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2278 NICE AVE
MENTONE CA
92359-9655
US

IV. Provider business mailing address

2278 NICE AVE
MENTONE CA
92359-9655
US

V. Phone/Fax

Practice location:
  • Phone: 909-794-1189
  • Fax: 909-389-7449
Mailing address:
  • Phone: 909-794-1189
  • Fax: 909-389-7449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number240000158
License Number StateCA

VIII. Authorized Official

Name: MS. VALERIE CANDELARIA
Title or Position: DIRECTOR OF AR
Credential:
Phone: 909-446-8754