NPIMap

Organization Active NPI

Executive Healthcare Services PLLC

  • Family Medicine Physician
  • Reston, VA
National Provider Identifier
1760664007
Registry record updated Aug 25, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
0101050406 Issued in VA
Legal business name
EXECUTIVE HEALTHCARE SERVICES PLLC
Practice address
12040 S Lakes Dr
Suite 195
Reston, VA 20191
Phone
(703) 230-0347
Fax
(703) 230-0350
NPI assigned
Nov 28, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 25, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Cheryl EcclestonNPI 1255572855
Title
Administrator
Phone
(703) 230-0347

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X 0101050406 VA Primary

Addresses

Primary practice location

12040 S Lakes Dr
Suite 195
Reston, VA 20191

Mailing address

12040 S Lakes Dr Ste 204
Reston, VA 20191-1236
Phone (703) 230-0347

Other practice location 1

7811 Montrose Rd # 530
Potomac, MD 20854-3363
Phone (240) 599-5400

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
49D2159857Executive Healthcare Services12040 South Lakes Dr #204, Reston, VA 20191Certificate of waiverDec 27, 2026

National Provider Directory

National Provider Directory

Locations

7811 Montrose Rd
Ste 530
Potomac, MD 20854
Phone (240) 599-5400

12040 South Lakes Dr
Ste 195
Reston, VA 20191
Phone (703) 230-0347

12040 South Lakes Dr
Ste 204
Reston, VA 20191
Phone (703) 230-0347

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1196208000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1661385600000",
    "number": "1760664007",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12040 S LAKES DR STE 204",
            "city": "RESTON",
            "state": "VA",
            "postal_code": "201911236",
            "telephone_number": "703-230-0347",
            "fax_number": "703-230-0350"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12040 S LAKES DR",
            "address_2": "SUITE 195",
            "city": "RESTON",
            "state": "VA",
            "postal_code": "20191",
            "telephone_number": "703-230-0347",
            "fax_number": "703-230-0350"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "7811 Montrose Rd # 530",
            "address_purpose": "LOCATION",
            "city": "Potomac",
            "state": "MD",
            "postal_code": "208543363",
            "country_code": "US",
            "telephone_number": "240-599-5400",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "EXECUTIVE HEALTHCARE SERVICES PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-11-28",
        "last_updated": "2022-08-25",
        "certification_date": "2022-08-25",
        "status": "A",
        "authorized_official_last_name": "ECCLESTON",
        "authorized_official_first_name": "CHERYL",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "703-230-0347"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": "VA",
            "license": "0101050406",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Reston, VA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 25, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.