MEDICARE: OLIVE BRANCH ASSISTED LIVING LLC

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	343900000X	Non-emergency Medical Transport (VAN)	50709	AZ

General Provider Information

NPI Number	:	1801394861
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLIVE BRANCH ASSISTED LIVING LLC

Provider Business Mailing Address
First Line	:	1121 N OLIVE AVE
Second Line	:
City	:	CASA GRANDE
State	:	AZ
Zip	:	85122-3418
Country	:	US
Telephone Number	:	602-618-3756
Fax Number	:

Provider Business Practice Location Address
First Line	:	1121 N OLIVE AVE
Second Line	:
City	:	CASA GRANDE
State	:	AZ
Zip	:	85122-3418
Country	:	US
Telephone Number	:	602-618-3756
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	RUSSELL ALLEN APPLETON
Credential	:
Telephone Number	:	602-618-3756

Provider Enumeration Date	:	01/24/2018
Last Update Date	:	01/24/2018

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