Provider Demographics
NPI:1336752963
Name:OLA WELLNESS RETREAT, LLC
Entity Type:Organization
Organization Name:OLA WELLNESS RETREAT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-975-5344
Mailing Address - Street 1:30765 PACIFIC COAST HWY STE 135
Mailing Address - Street 2:
Mailing Address - City:MALIBU
Mailing Address - State:CA
Mailing Address - Zip Code:90265-3643
Mailing Address - Country:US
Mailing Address - Phone:310-579-5192
Mailing Address - Fax:
Practice Address - Street 1:26924 PACIFIC COAST HWY
Practice Address - Street 2:
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90265-4356
Practice Address - Country:US
Practice Address - Phone:888-595-0235
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder