Provider Demographics
NPI:1932789757
Name:SHARED HARVEST FOUNDATION INC
Entity Type:Organization
Organization Name:SHARED HARVEST FOUNDATION INC
Other - Org Name:SHARED HARVEST MYCOVIDMD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:NANAEFUA
Authorized Official - Middle Name:
Authorized Official - Last Name:AFOH-MANIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-748-3832
Mailing Address - Street 1:23934 DECORAH RD
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-1407
Mailing Address - Country:US
Mailing Address - Phone:917-748-3832
Mailing Address - Fax:
Practice Address - Street 1:10000 WASHINGTON BLVD STE 600
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-2783
Practice Address - Country:US
Practice Address - Phone:323-880-0121
Practice Address - Fax:801-665-5652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-14
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB4082017Medicaid