MEDICARE: EXECUTIVE MEDICAL GROUP LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	251B00000X	Case Management Agency
2	251G00000X	Community Based Hospice Care Agency
3	251J00000X	Nursing Care Agency
4	253Z00000X	In Home Supportive Care Agency
5	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1194437707
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXECUTIVE MEDICAL GROUP LLC

Provider Business Mailing Address
First Line	:	8605 SANTA MONICA BLVD
Second Line	:
City	:	WEST HOLLYWOOD
State	:	CA
Zip	:	90069-4109
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1115 AQUA VISTA ST
Second Line	:	UNIT 405
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91602
Country	:	US
Telephone Number	:	310-381-9093
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. JEAN-CLAUDE KIARASH
Credential	:
Telephone Number	:	310-381-9093

Provider Enumeration Date	:	12/15/2022
Last Update Date	:	12/15/2022

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Directions to “EXECUTIVE MEDICAL GROUP LLC ” Practice Location

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