Provider Demographics
NPI:1801394861
Name:OLIVE BRANCH ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:OLIVE BRANCH ASSISTED LIVING LLC
Other - Org Name:TERRA MEDICAL TRANSPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:APPLETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-618-3756
Mailing Address - Street 1:1121 N OLIVE AVE
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-3418
Mailing Address - Country:US
Mailing Address - Phone:602-618-3756
Mailing Address - Fax:
Practice Address - Street 1:1121 N OLIVE AVE
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-3418
Practice Address - Country:US
Practice Address - Phone:602-618-3756
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-24
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ50709343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)