=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619403862
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GARDEN STATE I D LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2017
-----------------------------------------------------
Last Update Date | 05/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 36 HUNTINGTON RD
-----------------------------------------------------
City | EDISON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08820-3108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-660-5696
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36 HUNTINGTON ROAD
-----------------------------------------------------
City | ED
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-660-5696
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | M.D.
-----------------------------------------------------
Name | ARUNA SREE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 908-249-9512
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 405300000X
-----------------------------------------------------
Taxonomy Name | Prevention Professional
-----------------------------------------------------
License Number | 25MA08871700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------