Provider Demographics
NPI:1902252315
Name:SIDWA ENTERPRISE II, LLC
Entity type:Organization
Organization Name:SIDWA ENTERPRISE II, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:SIDWA
Authorized Official - Suffix:
Authorized Official - Credentials:ANP
Authorized Official - Phone:609-339-5667
Mailing Address - Street 1:1043 MONTAUK DR
Mailing Address - Street 2:
Mailing Address - City:FORKED RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08731-2004
Mailing Address - Country:US
Mailing Address - Phone:609-339-5667
Mailing Address - Fax:888-836-3950
Practice Address - Street 1:1043 MONTAUK DR
Practice Address - Street 2:
Practice Address - City:FORKED RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08731-2004
Practice Address - Country:US
Practice Address - Phone:609-339-5667
Practice Address - Fax:888-836-3950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-04
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NN10119300363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty