Provider Demographics
NPI:1194437707
Name:EXECUTIVE MEDICAL GROUP LLC
Entity type:Organization
Organization Name:EXECUTIVE MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEAN-CLAUDE
Authorized Official - Middle Name:
Authorized Official - Last Name:KIARASH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-381-9093
Mailing Address - Street 1:8605 SANTA MONICA BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-4109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1115 AQUA VISTA ST
Practice Address - Street 2:UNIT 405
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91602
Practice Address - Country:US
Practice Address - Phone:310-381-9093
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-15
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251B00000XAgenciesCase Management
No251G00000XAgenciesHospice Care, Community Based
No251J00000XAgenciesNursing Care
No253Z00000XAgenciesIn Home Supportive Care