Provider Demographics
NPI:1225127426
Name:OLIVE BRANCH RESIDENTIAL, LLC
Entity Type:Organization
Organization Name:OLIVE BRANCH RESIDENTIAL, LLC
Other - Org Name:OLIVE GROVE TERRACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:REIKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-895-7609
Mailing Address - Street 1:9684 OLD GOODMAN ROAD
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654
Mailing Address - Country:US
Mailing Address - Phone:662-895-7609
Mailing Address - Fax:662-895-3501
Practice Address - Street 1:9684 OLD GOODMAN ROAD
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654
Practice Address - Country:US
Practice Address - Phone:662-895-7609
Practice Address - Fax:662-895-3501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility