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General NPI Number Information
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NPI Number | 1053973230
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Entity Type | Organization
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Legal Business Name | OLA WELLNESS RETREAT, LLC
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Dates
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Enumeration Date | 07/08/2019
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Last Update Date | 06/16/2022
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Provider Practice Location Address
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Address Line | 30425 PACIFIC COAST HWY
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City | MALIBU
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State | CA
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Zip | 90265-3604
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Country | US
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Telephone | 888-595-0235
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Fax |
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Provider Business Mailing Address
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Address Line | 30765 PACIFIC COAST HWY STE 135
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City | MALIBU
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State | CA
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Zip | 90265-3643
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CO-CEO
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Name | EVAN HAINES
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Credential |
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Telephone | 310-975-5344
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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