Healthcare Provider Details

I. General information

NPI: 1174168397
Provider Name (Legal Business Name): OLIVE CREST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2019
Last Update Date: 12/15/2023
Certification Date: 12/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20051 VISTA DEL LAGO STE B
PERRIS CA
92570-7170
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 951-238-1936
  • Fax:
Mailing address:
  • Phone: 714-543-5437
  • Fax: 714-543-5463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: DONALD VERLEUR
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MBA
Phone: 714-543-5437