Basic Information
| Provider Information | |||||||||
| NPI: | 1982675328 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRASWELLS VILLA MONTE VISTA LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12696 MONTE VISTA RD | ||||||||
| Address2: | |||||||||
| City: | POWAY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920642500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584876242 | ||||||||
| FaxNumber: | 8584874282 | ||||||||
| Practice Location | |||||||||
| Address1: | 12696 MONTE VISTA RD | ||||||||
| Address2: | |||||||||
| City: | POWAY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920642500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584876242 | ||||||||
| FaxNumber: | 8584874282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CANDELARIA | ||||||||
| AuthorizedOfficialFirstName: | VALERIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF AR | ||||||||
| AuthorizedOfficialTelephone: | 9094468754 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | LTC55206H | 05 | CA | MEDICAID |