Provider Demographics
NPI:1598402216
Name:THE OLIVE FOUNDATION LLC
Entity Type:Organization
Organization Name:THE OLIVE FOUNDATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:OGU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-612-2231
Mailing Address - Street 1:6638 S 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-5764
Mailing Address - Country:US
Mailing Address - Phone:602-612-2231
Mailing Address - Fax:602-429-8462
Practice Address - Street 1:820 S BRIDGER DR
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-6490
Practice Address - Country:US
Practice Address - Phone:602-612-2231
Practice Address - Fax:602-429-8462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-14
Last Update Date:2022-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities