Healthcare Provider Details

I. General information

NPI: 1215873088
Provider Name (Legal Business Name): EXECUTIVE RESIDENTIAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2026
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

856 N WEST ST
ANAHEIM CA
92801-4302
US

IV. Provider business mailing address

856 N WEST ST
ANAHEIM CA
92801-4302
US

V. Phone/Fax

Practice location:
  • Phone: 949-258-3663
  • Fax:
Mailing address:
  • Phone: 949-258-3663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. GENESIS JOHNSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 562-230-9589