Provider Demographics
NPI:1942702055
Name:EXECUTIVE RECOVERY GROUP, INC
Entity type:Organization
Organization Name:EXECUTIVE RECOVERY GROUP, INC
Other - Org Name:<UNAVAIL>
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 1:77725 ENFIELD LN
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211-0468
Mailing Address - Country:US
Mailing Address - Phone:760-409-1287
Mailing Address - Fax:
Practice Address - Street 1:77725 ENFIELD LN # 100-200
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211
Practice Address - Country:US
Practice Address - Phone:760-345-7239
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EXECUTIVE RECOVERY GROUP, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-05
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA330143BP261QM1300X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty