Healthcare Provider Details

I. General information

NPI: 1578060919
Provider Name (Legal Business Name): OLIVE CREST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2018
Last Update Date: 04/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 N WHEELER ST
ORANGE CA
92869-3217
US

IV. Provider business mailing address

2130 E 4TH ST STE 200
SANTA ANA CA
92705-3818
US

V. Phone/Fax

Practice location:
  • Phone: 714-532-5096
  • Fax: 714-532-4683
Mailing address:
  • Phone: 714-543-5437
  • Fax: 714-543-5463

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: MR. DONALD A. VERLEUR II
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MBA
Phone: 714-543-5437