Basic Information
| Provider Information | |||||||||
| NPI: | 1659878809 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OLIVE CREST | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CYS OLIVE CREST MALENA HOUSE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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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: | 13442 MALENA DR | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927051912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148323629 | ||||||||
| FaxNumber: | 7147314393 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2018 | ||||||||
| LastUpdateDate: | 06/04/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VERLEUR | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7145435437 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | MBA | ||||||||
| NPICertificationDate: | 06/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
No ID Information.