Healthcare Provider Details

I. General information

NPI: 1699400788
Provider Name (Legal Business Name): CENTENNIAL HARVEST WELLNESS INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2022
Last Update Date: 07/21/2022
Certification Date: 07/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2330 E DEL MAR BLVD
PASADENA CA
91107
US

IV. Provider business mailing address

3355 N WHITE AVE UNIT 8287
LA VERNE CA
91750-6207
US

V. Phone/Fax

Practice location:
  • Phone: 323-917-1195
  • Fax:
Mailing address:
  • Phone: 323-917-1195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MS. LEEANN MARIE NABORS
Title or Position: PRESIDENT-CEO
Credential:
Phone: 323-917-1195