MEDICARE: OLIVE CREST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760879225
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLIVE CREST

Provider Business Mailing Address
First Line	:	2130 E 4TH ST STE 200
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92705-3818
Country	:	US
Telephone Number	:	714-543-5437
Fax Number	:	714-543-5463

Provider Business Practice Location Address
First Line	:	805-807 N CENTRAL AVE
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91203-1230
Country	:	US
Telephone Number	:	818-630-7480
Fax Number	:	818-563-2342

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MR. DONALD A. VERLEUR II
Credential	:	MBA
Telephone Number	:	714-543-5437

Provider Enumeration Date	:	04/22/2015
Last Update Date	:	04/10/2019

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Directions to “OLIVE CREST ” Practice Location

Language	Start Address	Practice Location

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