Provider Demographics
NPI:1922652296
Name:EXECUTIVE RECOVERY GROUP, INC
Entity Type:Organization
Organization Name:EXECUTIVE RECOVERY GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:CRICHTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-200-3839
Mailing Address - Street 1:35450 PEGASUS CT
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211-1604
Mailing Address - Country:US
Mailing Address - Phone:760-409-1287
Mailing Address - Fax:
Practice Address - Street 1:15613 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-3128
Practice Address - Country:US
Practice Address - Phone:760-409-1287
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EXECUTIVE RECOVERY GROUP, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-07-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA190042CPOtherDEPARTMENT OF HEALTH CARE SERVICES