Healthcare Provider Details

I. General information

NPI: 1740468008
Provider Name (Legal Business Name): NEW DESTINATON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2008
Last Update Date: 04/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1424 PENNSYLVANIA AVE SE
WASHINGTON DC
20003-3029
US

IV. Provider business mailing address

1424 PENNSYLVANIA AVE SE
WASHINGTON DC
20003-3029
US

V. Phone/Fax

Practice location:
  • Phone: 202-546-0000
  • Fax:
Mailing address:
  • Phone: 202-546-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. CHARLES WESTLY AVERYT
Title or Position: CLINICAL DIRECTOR
Credential: LICSW
Phone: 202-546-0000