Provider Demographics
NPI:1598180648
Name:OLIVE GROVE REAL ESTATE LLC
Entity Type:Organization
Organization Name:OLIVE GROVE REAL ESTATE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:AARON
Authorized Official - Middle Name:
Authorized Official - Last Name:BENTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-495-7000
Mailing Address - Street 1:3014 E INDIAN SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-6887
Mailing Address - Country:US
Mailing Address - Phone:623-505-4668
Mailing Address - Fax:
Practice Address - Street 1:3014 E INDIAN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-6887
Practice Address - Country:US
Practice Address - Phone:623-505-4668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STELLAR SENIOR LIVING LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-02-26
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL9164C310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ884722Medicaid