Healthcare Provider Details

I. General information

NPI: 1649108903
Provider Name (Legal Business Name): HARVEST SAFE HAVEN FOR BOYS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2026
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8905 DRIFTWOOD DR
RIVERSIDE CA
92503-2120
US

IV. Provider business mailing address

3380 LA SIERRA AVE STE 104-242
RIVERSIDE CA
92503-5271
US

V. Phone/Fax

Practice location:
  • Phone: 951-715-3126
  • Fax:
Mailing address:
  • Phone: 951-715-3126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: DANIEL PARK
Title or Position: CEO
Credential:
Phone: 951-715-3126