Provider Demographics
NPI:1568974418
Name:SIVAM DIABETES, NUTRITION AND FAMILY HEALTHCARE LLC
Entity Type:Organization
Organization Name:SIVAM DIABETES, NUTRITION AND FAMILY HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/SOCIAL ENTREPRENEUR
Authorized Official - Prefix:DR
Authorized Official - First Name:MAVIS
Authorized Official - Middle Name:CAMALITA
Authorized Official - Last Name:FAULKNOR
Authorized Official - Suffix:
Authorized Official - Credentials:FNP, APN, RN, RD, CD
Authorized Official - Phone:201-618-1472
Mailing Address - Street 1:78 KENMORE AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07106
Mailing Address - Country:US
Mailing Address - Phone:201-618-1472
Mailing Address - Fax:973-399-3393
Practice Address - Street 1:240 N ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07017-3802
Practice Address - Country:US
Practice Address - Phone:201-618-1472
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-01
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0071705133VN1006X
NJ26NR11201600163WD0400X
NJ26NJ00421400363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Multi-Specialty
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Multi-Specialty