Organization
SIVAM DIABETES & PRIMARY CARE LLC
Active
Other names
SIVAM DIABETES, NUTRITION AND FAMILY HEALTHCARE
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MAVIS CAMALITA ERMAKOV DNP, APN, FHNP-BC, R (DIRECTOR/CEO)
(201) 618-1472
Entity
Organization
Contact information
Practice address
1120-1122 SOUTH ORANGE AVENUE, NEWARK, NJ 07106
(201) 618-1472
Mailing address
78 KENMORE AVE, NEWARK, NJ 07106-1026
(201) 618-1472
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
—
—
163WD0400X
Diabetes Educator Registered Nurse
—
—
261QH0100X
Health Service Clinic/Center
—
—
363LF0000X
Family Nurse Practitioner
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0143533620
—
NJ
Enumeration date
12/11/2019
Last updated
09/01/2021
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