Organization
BRASWELLS IVY RETREAT LTD
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. VALERIE CANDELARIA (DIRECTOR OF AR)
(909) 446-8754
Entity
Organization
Contact information
Practice address
2278 NICE AVE, MENTONE, CA 92359-9655
(909) 794-1189
(909) 389-7449
Mailing address
2278 NICE AVE, MENTONE, CA 92359-9655
(909) 794-1189
(909) 389-7449
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
240000158
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
555025
MEDICARE PROVIDER NUMBER
CA
05
—
ZZT05985I
—
CA
Enumeration date
02/01/2006
Last updated
06/30/2008
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