Provider Demographics
NPI:1760879225
Name:OLIVE CREST
Entity Type:Organization
Organization Name:OLIVE CREST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:A
Authorized Official - Last Name:VERLEUR
Authorized Official - Suffix:II
Authorized Official - Credentials:MBA
Authorized Official - Phone:714-543-5437
Mailing Address - Street 1:2130 E 4TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3818
Mailing Address - Country:US
Mailing Address - Phone:714-543-5437
Mailing Address - Fax:714-543-5463
Practice Address - Street 1:805-807 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-1230
Practice Address - Country:US
Practice Address - Phone:818-630-7480
Practice Address - Fax:818-563-2342
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OLIVE CREST
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-22
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7964Medicaid