Provider Demographics
NPI:1710177068
Name:GAVIOTA CORPORATION
Entity Type:Organization
Organization Name:GAVIOTA CORPORATION
Other - Org Name:GAVIOTA CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:SILEGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-368-4130
Mailing Address - Street 1:559 BROADWAY APT 12
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-4151
Mailing Address - Country:US
Mailing Address - Phone:973-368-4130
Mailing Address - Fax:973-732-0023
Practice Address - Street 1:919 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-4801
Practice Address - Country:US
Practice Address - Phone:973-368-4130
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center