Healthcare Provider Details

I. General information

NPI: 1326478819
Provider Name (Legal Business Name): DSWLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2013
Last Update Date: 11/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 OLD RARITAN RD
EDISON NJ
08820-1021
US

IV. Provider business mailing address

725 OLD RARITAN RD
EDISON NJ
08820-1021
US

V. Phone/Fax

Practice location:
  • Phone: 908-668-1766
  • Fax:
Mailing address:
  • Phone: 908-668-1766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number26NR08930300
License Number StateNJ

VIII. Authorized Official

Name: MR. DAVID SMALLWOOD WEAVER
Title or Position: PRESIDENT
Credential: RNFA
Phone: 908-668-1766