Provider Demographics
NPI:1104494814
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:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:VERLEUR
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:714-543-5437
Mailing Address - Street 1:2130 E 4TH ST
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:
Practice Address - Street 1:39830 PORTOLA AVE
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-0623
Practice Address - Country:US
Practice Address - Phone:951-686-8500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-17
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33Q8Medicaid