Healthcare Provider Details

I. General information

NPI: 1245863281
Provider Name (Legal Business Name): DIABETICWATCHERS USA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2020
Last Update Date: 02/18/2020
Certification Date: 02/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 GALESI DR STE 104B
WAYNE NJ
07470-4840
US

IV. Provider business mailing address

30 GALESI DR STE 104B
WAYNE NJ
07470-4840
US

V. Phone/Fax

Practice location:
  • Phone: 201-577-8994
  • Fax:
Mailing address:
  • Phone: 201-577-8994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QC1800X
TaxonomyCorporate Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QP0905X
TaxonomyState or Local Public Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: MRS. OERMILA CORRAO
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 201-577-8994