Healthcare Provider Details

I. General information

NPI: 1619839941
Provider Name (Legal Business Name): THE HARVEST HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2025
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11915 BERLYN DOVE CT
JURUPA VALLEY CA
91752-2927
US

IV. Provider business mailing address

6885 CEDAR CREEK RD
EASTVALE CA
92880-8805
US

V. Phone/Fax

Practice location:
  • Phone: 951-332-0421
  • Fax: 951-332-0288
Mailing address:
  • Phone: 951-332-0421
  • Fax: 951-332-0288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: SIMM KESONE SANASINH
Title or Position: OWNER
Credential: ADMINISTRATOR
Phone: 949-233-1645