1750352191 NPI number — BRASWELLS IVY RETREAT LTD

Table of content: (NPI 1750352191)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750352191 NPI number — BRASWELLS IVY RETREAT LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRASWELLS IVY RETREAT LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750352191
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2278 NICE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MENTONE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92359-9655
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-794-1189
Provider Business Mailing Address Fax Number:
909-389-7449

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2278 NICE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MENTONE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92359-9655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-794-1189
Provider Business Practice Location Address Fax Number:
909-389-7449
Provider Enumeration Date:
02/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CANDELARIA
Authorized Official First Name:
VALERIE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF AR
Authorized Official Telephone Number:
909-446-8754

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  240000158 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZZT05985I , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 555025 . This is a "MEDICARE PROVIDER NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com