Provider Demographics
NPI:1306817747
Name:BRASWELLS YUCAIPA VALLEY CONVALESCENT LP
Entity Type:Organization
Organization Name:BRASWELLS YUCAIPA VALLEY CONVALESCENT LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF AR
Authorized Official - Prefix:MS
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CANDELARIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-446-8754
Mailing Address - Street 1:35253 AVENUE H
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-5415
Mailing Address - Country:US
Mailing Address - Phone:909-795-2476
Mailing Address - Fax:909-795-0458
Practice Address - Street 1:35253 AVENUE H
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-5415
Practice Address - Country:US
Practice Address - Phone:909-795-2476
Practice Address - Fax:909-795-0458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-01
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT05557GMedicaid
CA055557OtherMEDICARE PROVIDER NUMBER
CA055557Medicare Oscar/Certification
CA055557Medicare ID - Type Unspecified