MEDICARE: SIVAM DIABETES, NUTRITION AND FAMILY HEALTHCARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WD0400X	Diabetes Educator Registered Nurse	26NR11201600	NJ
2	133VN1006X	Metabolic Nutrition Registered Dietitian	0071705	IL
3	363LF0000X	Family Nurse Practitioner	26NJ00421400	NJ

General Provider Information

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

Provider Business Mailing Address
First Line	:	78 KENMORE AVENUE
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07106
Country	:	US
Telephone Number	:	201-618-1472
Fax Number	:	973-399-3393

Provider Business Practice Location Address
First Line	:	240 N ARLINGTON AVE
Second Line	:
City	:	EAST ORANGE
State	:	NJ
Zip	:	07017-3802
Country	:	US
Telephone Number	:	201-618-1472
Fax Number	:

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

Provider Enumeration Date	:	11/01/2017
Last Update Date	:	11/01/2017

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