Healthcare Provider Details

I. General information

NPI: 1285288316
Provider Name (Legal Business Name): OLIVE CREST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2019
Last Update Date: 11/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23115 RIDER ST
PERRIS CA
92570-9723
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 951-686-8500
  • Fax:
Mailing address:
  • Phone: 714-543-5437
  • Fax:

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: CEO
Credential: MBA
Phone: 714-543-5437