1780671172 NPI number — BRASWELLS COLONIAL CARE OF REDLANDS

Table of content: (NPI 1780671172)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780671172 NPI number — BRASWELLS COLONIAL CARE OF REDLANDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRASWELLS COLONIAL CARE OF REDLANDS
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:
6
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:
1780671172
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/28/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1618 LAUREL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REDLANDS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92373-4838
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-792-6050
Provider Business Mailing Address Fax Number:
909-798-8341

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1618 LAUREL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REDLANDS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92373-4838
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-792-6050
Provider Business Practice Location Address Fax Number:
909-798-8341
Provider Enumeration Date:
09/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BRASWELL
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
H.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
909-795-3821

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  240000307 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , 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: LTC55350F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com