Provider Demographics
NPI:1750352191
Name:BRASWELLS IVY RETREAT LTD
Entity type:Organization
Organization Name:BRASWELLS IVY RETREAT LTD
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 1:2278 NICE AVE
Mailing Address - Street 2:
Mailing Address - City:MENTONE
Mailing Address - State:CA
Mailing Address - Zip Code:92359-9655
Mailing Address - Country:US
Mailing Address - Phone:909-794-1189
Mailing Address - Fax:909-389-7449
Practice Address - Street 1:2278 NICE AVE
Practice Address - Street 2:
Practice Address - City:MENTONE
Practice Address - State:CA
Practice Address - Zip Code:92359-9655
Practice Address - Country:US
Practice Address - Phone:909-794-1189
Practice Address - Fax:909-389-7449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-01
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240000158314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT05985IMedicaid
CA555025OtherMEDICARE PROVIDER NUMBER
CAZZT05985IMedicaid
CA555025Medicare Oscar/Certification