MEDICARE: OLIVE CARE RESIDENTIAL INC

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	2084P0005X	Neurodevelopmental Disabilities Physician

General Provider Information

NPI Number	:	1871325621
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLIVE CARE RESIDENTIAL INC

Provider Business Mailing Address
First Line	:	1653 S SENECA AVE
Second Line	:
City	:	ALLIANCE
State	:	OH
Zip	:	44601-4356
Country	:	US
Telephone Number	:	330-356-4420
Fax Number	:

Provider Business Practice Location Address
First Line	:	1653 S SENECA AVE
Second Line	:
City	:	ALLIANCE
State	:	OH
Zip	:	44601-4356
Country	:	US
Telephone Number	:	330-356-4420
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JARVIS MACK
Credential	:
Telephone Number	:	330-356-4420

Provider Enumeration Date	:	08/19/2024
Last Update Date	:	08/19/2024

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