Basic Information
Provider Information | |||||||||
NPI: | 1285092106 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HARVEST RETIREMENT CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9011 KNOTT AVE | ||||||||
Address2: |   | ||||||||
City: | BUENA PARK | ||||||||
State: | CA | ||||||||
PostalCode: | 906204138 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7148214130 | ||||||||
FaxNumber: | 9496081588 | ||||||||
Practice Location | |||||||||
Address1: | 9011 KNOTT AVE | ||||||||
Address2: |   | ||||||||
City: | BUENA PARK | ||||||||
State: | CA | ||||||||
PostalCode: | 906204138 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7148214130 | ||||||||
FaxNumber: | 9496081588 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/06/2016 | ||||||||
LastUpdateDate: | 02/06/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PO | ||||||||
AuthorizedOfficialFirstName: | GINGER | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9496482737 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3104A0630X | 306005207 | CA | N |   | Nursing & Custodial Care Facilities | Assisted Living Facility | Assisted Living, Behavioral Disturbances | 311500000X | 306005207 | CA | N |   | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) |   | 315D00000X | 306005207 | CA | N |   | Nursing & Custodial Care Facilities | Hospice, Inpatient |   | 310400000X | 306005207 | CA | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
No ID Information.