Healthcare Provider Details

I. General information

NPI: 1265971261
Provider Name (Legal Business Name): TELADIETITIAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2017
Last Update Date: 02/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

471 NORTH BROADWAY, 363
JERICHO NY
11753
US

IV. Provider business mailing address

471 N BROADWAY # 363
JERICHO NY
11753-2106
US

V. Phone/Fax

Practice location:
  • Phone: 917-535-3626
  • Fax:
Mailing address:
  • Phone: 917-535-3626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: JACQUELINE ARNETT
Title or Position: CEO
Credential: RD, ESQ.
Phone: 917-535-3626