Provider Demographics
NPI:1568140986
Name:1017 N OLIVE LLC
Entity Type:Organization
Organization Name:1017 N OLIVE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOROTKEVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-222-1719
Mailing Address - Street 1:301 E YAMATO RD STE 1130
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-4929
Mailing Address - Country:US
Mailing Address - Phone:561-222-1719
Mailing Address - Fax:
Practice Address - Street 1:1017 N OLIVE AVE
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-3511
Practice Address - Country:US
Practice Address - Phone:561-222-1719
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)