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General NPI Number Information
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NPI Number | 1750352191
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Entity Type | Organization
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Legal Business Name | BRASWELLS IVY RETREAT LTD
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Dates
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Enumeration Date | 02/01/2006
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Last Update Date | 06/30/2008
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Provider Practice Location Address
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Address Line | 2278 NICE AVE
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City | MENTONE
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State | CA
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Zip | 92359-9655
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Country | US
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Telephone | 909-794-1189
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Fax | 909-389-7449
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Provider Business Mailing Address
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Address Line | 2278 NICE AVE
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City | MENTONE
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State | CA
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Zip | 92359-9655
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Country | US
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Telephone | 909-794-1189
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Fax | 909-389-7449
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Authorized Official
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Title or Position | DIRECTOR OF AR
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Name | MS. VALERIE CANDELARIA
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Credential |
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Telephone | 909-446-8754
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 240000158
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License Number State | CA
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