Provider Demographics
NPI:1699191775
Name:OLIVE GROVE LLC
Entity Type:Organization
Organization Name:OLIVE GROVE LLC
Other - Org Name:OLIVE GROVE RESIDENTIAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE OFFICER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-981-9081
Mailing Address - Street 1:723 E KIRKWALL RD
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-5715
Mailing Address - Country:US
Mailing Address - Phone:714-981-9081
Mailing Address - Fax:702-359-1983
Practice Address - Street 1:9446 BACK BAY CIR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-5947
Practice Address - Country:US
Practice Address - Phone:702-413-6947
Practice Address - Fax:702-359-1983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-12
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV76654GC-1311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home