Provider Demographics
NPI:1619403862
Name:GARDEN STATE I D LLC
Entity Type:Organization
Organization Name:GARDEN STATE I D LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:ARUNA
Authorized Official - Middle Name:
Authorized Official - Last Name:SREE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-249-9512
Mailing Address - Street 1:36 HUNTINGTON ROAD
Mailing Address - Street 2:
Mailing Address - City:ED
Mailing Address - State:NJ
Mailing Address - Zip Code:08820
Mailing Address - Country:US
Mailing Address - Phone:646-660-5696
Mailing Address - Fax:
Practice Address - Street 1:36 HUNTINGTON RD
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-3108
Practice Address - Country:US
Practice Address - Phone:646-660-5696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-10
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08871700405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes405300000XOther Service ProvidersPrevention ProfessionalGroup - Single Specialty