Healthcare Provider Details

I. General information

NPI: 1780353086
Provider Name (Legal Business Name): MADISON KELLY BUSCH RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2021
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13123 E 16TH AVE # B32
AURORA CO
80045-7106
US

IV. Provider business mailing address

2600 MOLINE ST
DENVER CO
80238-4113
US

V. Phone/Fax

Practice location:
  • Phone: 614-580-6673
  • Fax:
Mailing address:
  • Phone: 614-580-6673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86078852
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number352
License Number StateWY
# 3
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: