MEDICARE: OLIVE BRANCH SUPPORTIVE SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	NV20151522250	NV

General Provider Information

NPI Number	:	1194196881
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLIVE BRANCH SUPPORTIVE SERVICES LLC

Provider Business Mailing Address
First Line	:	6012 HARVEST DANCE ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-2063
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6012 HARVEST DANCE ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-2063
Country	:	US
Telephone Number	:	702-747-1066
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TIFFANY SCOTT
Credential	:
Telephone Number	:	702-747-1066

Provider Enumeration Date	:	10/07/2015
Last Update Date	:	10/07/2015

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