Healthcare Provider Details

I. General information

NPI: 1568974418
Provider Name (Legal Business Name): SIVAM DIABETES, NUTRITION AND FAMILY HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2017
Last Update Date: 11/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 N ARLINGTON AVE
EAST ORANGE NJ
07017-3802
US

IV. Provider business mailing address

78 KENMORE AVENUE
NEWARK NJ
07106
US

V. Phone/Fax

Practice location:
  • Phone: 201-618-1472
  • Fax:
Mailing address:
  • Phone: 201-618-1472
  • Fax: 973-399-3393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number26NR11201600
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number0071705
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00421400
License Number StateNJ

VIII. Authorized Official

Name: DR. MAVIS CAMALITA FAULKNOR
Title or Position: CEO/SOCIAL ENTREPRENEUR
Credential: FNP, APN, RN, RD, CD
Phone: 201-618-1472