Healthcare Provider Details

I. General information

NPI: 1154296879
Provider Name (Legal Business Name): OLIVE GROVE COMMUNITY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2025
Last Update Date: 02/26/2026
Certification Date: 02/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 MCCLEAN AVE
STATEN ISLAND NY
10305-4667
US

IV. Provider business mailing address

114 MCCLEAN AVE
STATEN ISLAND NY
10305-4667
US

V. Phone/Fax

Practice location:
  • Phone: 917-500-0500
  • Fax:
Mailing address:
  • Phone: 917-500-0500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: FATENAH ADEL ASAD-ABUZAHARIEH
Title or Position: OWNER
Credential:
Phone: 646-377-5672