Provider Demographics
NPI:1053861450
Name:OLIVE CREST
Entity Type:Organization
Organization Name:OLIVE CREST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:A
Authorized Official - Last Name:VERLEUR
Authorized Official - Suffix:II
Authorized Official - Credentials:MBA
Authorized Official - Phone:714-543-5437
Mailing Address - Street 1:2130 E 4TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3818
Mailing Address - Country:US
Mailing Address - Phone:714-543-5437
Mailing Address - Fax:714-543-5463
Practice Address - Street 1:39820 PORTOLA AVE
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-0622
Practice Address - Country:US
Practice Address - Phone:760-341-8507
Practice Address - Fax:760-341-8613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-10
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57111251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALE0518OtherMEDI-CAL