Provider Demographics
NPI:1063131407
Name:EXECUTIVE RESIDENTIAL CARE & RECOVERY LLC
Entity type:Organization
Organization Name:EXECUTIVE RESIDENTIAL CARE & RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOC. DIRECTOR OF PATIENT ACCT
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:MORA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-576-1284
Mailing Address - Street 1:11627 TELEGRAPH RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SANTA FE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:90670-6814
Mailing Address - Country:US
Mailing Address - Phone:562-576-1284
Mailing Address - Fax:562-861-0883
Practice Address - Street 1:70806 HALPER LAKE DR
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-2523
Practice Address - Country:US
Practice Address - Phone:760-832-8810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-26
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness