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General NPI Number Information
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NPI Number | 1477290484
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Entity Type | Individual
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Provider Name | AJAY PHILIP KOLETH
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Gender | Male
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Dates
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Enumeration Date | 05/19/2022
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Last Update Date | 10/27/2022
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Provider Practice Location Address
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Address Line | 220 W ELK AVE
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City | ELIZABETHTON
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State | TN
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Zip | 37643-2612
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Country | US
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Telephone | 423-561-1623
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Fax |
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Provider Business Mailing Address
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Address Line | 220 W ELK AVE
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City | ELIZABETHTON
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State | TN
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Zip | 37643-2612
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Country | US
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Telephone | 423-561-1623
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133NN1002X
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Taxonomy Name | Nutrition Education Nutritionist
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License Number |
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License Number State | TN
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