=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609153402
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRASWELL'S LEISURE MANOR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2011
-----------------------------------------------------
Last Update Date | 11/08/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32195 AVENUE E
-----------------------------------------------------
City | YUCAIPA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92399-1797
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-797-1314
-----------------------------------------------------
Fax | 909-797-9321
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 32195 AVENUE E
-----------------------------------------------------
City | YUCAIPA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92399-1797
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-797-1314
-----------------------------------------------------
Fax | 909-797-9321
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. JANET ERIN PICCINATI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-797-1314
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 360900100
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------