Basic Information
| Provider Information | |||||||||
| NPI: | 1720551971 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OLIVE CREST | ||||||||
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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 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4510 E PACIFIC COAST HWY STE 450 | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908046924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628668956 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2019 | ||||||||
| LastUpdateDate: | 01/09/2019 | ||||||||
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| AuthorizedOfficialLastName: | VERLEUR | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7145435437 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.