# BRASWELLS IVY RETREAT LTD

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1750352191
- **Authorized official:** MS. VALERIE CANDELARIA (DIRECTOR OF AR)
- **Authorized official phone:** (909) 446-8754

## Contact information

- **Practice address:** 2278 NICE AVE, MENTONE, CA 92359-9655
- **Practice address phone:** (909) 794-1189
- **Practice address fax:** (909) 389-7449
- **Mailing address:** 2278 NICE AVE, MENTONE, CA 92359-9655
- **Mailing address phone:** (909) 794-1189
- **Mailing address fax:** (909) 389-7449

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 314000000X | Skilled Nursing Facility | 240000158 | CA | Yes |

## Other

- **Enumeration date:** 02/01/2006
- **Last updated:** 06/30/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 555025 | MEDICARE PROVIDER NUMBER | CA |
| 05 | — | ZZT05985I | — | CA |