Provider Demographics
NPI:1508480765
Name:OLIVE BRANCH RECOVERY LLC
Entity Type:Organization
Organization Name:OLIVE BRANCH RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MILES
Authorized Official - Middle Name:
Authorized Official - Last Name:RAIZADA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:940-220-8899
Mailing Address - Street 1:1332 TEASLEY LN STE 180
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76205-7946
Mailing Address - Country:US
Mailing Address - Phone:940-220-8899
Mailing Address - Fax:940-294-1772
Practice Address - Street 1:1332 TEASLEY LN STE 180
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76205-7946
Practice Address - Country:US
Practice Address - Phone:940-220-8899
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-03
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No276400000XHospital UnitsRehabilitation, Substance Use Disorder UnitGroup - Single Specialty