=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447992961
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVESTA ALTERNATIVE CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2022
-----------------------------------------------------
Last Update Date | 04/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6861 ELM ST STE 3E
-----------------------------------------------------
City | MC LEAN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22101-6036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-646-6343
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1268 BEVERLY RD
-----------------------------------------------------
City | MC LEAN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22101-2834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-201-7767
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. LADAN ESHKEVARI
-----------------------------------------------------
Credential | PHD, CRNA
-----------------------------------------------------
Telephone | 703-201-7767
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------