Provider Demographics
NPI:1316045388
Name:THE OLIVE LEAF
Entity Type:Organization
Organization Name:THE OLIVE LEAF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:FRIEDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:818-231-4283
Mailing Address - Street 1:19133 INGOMAR ST
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-1720
Mailing Address - Country:US
Mailing Address - Phone:818-360-3317
Mailing Address - Fax:818-357-2437
Practice Address - Street 1:19133 INGOMAR ST
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-1720
Practice Address - Country:US
Practice Address - Phone:818-360-3317
Practice Address - Fax:818-357-2437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
315P00000X
CA960001402320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities