Healthcare Provider Details

I. General information

NPI: 1659778256
Provider Name (Legal Business Name): GREGORY CARLETON COOLIDGE II C.H.W.C., C.F.N.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2014
Last Update Date: 11/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 LITTLE ROUND TOP #315
FORT THOMAS KY
41075-4417
US

IV. Provider business mailing address

240 LITTLE ROUND TOP #315
FORT THOMAS KY
41075-4417
US

V. Phone/Fax

Practice location:
  • Phone: 859-757-7060
  • Fax:
Mailing address:
  • Phone: 859-757-7060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: