Provider Demographics
NPI:1578841029
Name:OLIVE GARDEN HEALTHCARE SERV. LLC
Entity Type:Organization
Organization Name:OLIVE GARDEN HEALTHCARE SERV. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DORCAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLAJI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-907-2089
Mailing Address - Street 1:1231 SWEETGUM TRL
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-3593
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:90 COMMERCE DR STE A
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7519
Practice Address - Country:US
Practice Address - Phone:800-256-5005
Practice Address - Fax:404-889-8661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAO56-R-0865251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care