Provider Demographics
NPI:1295937415
Name:HARVESTMOON ICFDDN
Entity type:Organization
Organization Name:HARVESTMOON ICFDDN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR-OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:YOLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUME
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:626-665-8938
Mailing Address - Street 1:1017 E HARVEST MOON ST
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792-1023
Mailing Address - Country:US
Mailing Address - Phone:626-665-8938
Mailing Address - Fax:925-516-7106
Practice Address - Street 1:1017 E HARVEST MOON ST
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91792-1023
Practice Address - Country:US
Practice Address - Phone:626-665-8938
Practice Address - Fax:925-516-7106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA960001418313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility