Healthcare Provider Details

I. General information

NPI: 1316045388
Provider Name (Legal Business Name): THE OLIVE LEAF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 01/19/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19133 INGOMAR ST
RESEDA CA
91335-1720
US

IV. Provider business mailing address

19133 INGOMAR ST
RESEDA CA
91335-1720
US

V. Phone/Fax

Practice location:
  • Phone: 818-360-3317
  • Fax: 818-357-2437
Mailing address:
  • Phone: 818-360-3317
  • Fax: 818-357-2437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number960001402
License Number StateCA

VIII. Authorized Official

Name: MR. LARRY PHILIP FRIEDMAN
Title or Position: ADMINISTRATOR
Credential: M.A.
Phone: 818-231-4283