Basic Information
Provider Information
NPI: 1396950374
EntityType: 2
ReplacementNPI:  
OrganizationName: OLIVE CREST
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
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Mailing Information
Address1: 2130 E 4TH ST STE 200
Address2:  
City: SANTA ANA
State: CA
PostalCode: 927053818
CountryCode: US
TelephoneNumber: 7145435437
FaxNumber: 7145435463
Practice Location
Address1: 4285 N RANCHO DR STE 160
Address2:  
City: LAS VEGAS
State: NV
PostalCode: 891303456
CountryCode: US
TelephoneNumber: 7026853459
FaxNumber: 7028518528
Other Information
ProviderEnumerationDate: 05/11/2007
LastUpdateDate: 04/11/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: VERLEUR
AuthorizedOfficialFirstName: DONALD
AuthorizedOfficialMiddleName: A.
AuthorizedOfficialTitleorPosition: CHIEF EXECUTIVE OFFICER
AuthorizedOfficialTelephone: 7145435437
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix: II
AuthorizedOfficialCredential: MBA
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
253J00000X NVN AgenciesFoster Care Agency 
251S00000X NVY AgenciesCommunity/Behavioral Health 

ID Information
IDTypeStateIssuerDescription
10050832605NV MEDICAID
10050832505NV MEDICAID
10050832005NV MEDICAID


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