Healthcare Provider Details

I. General information

NPI: 1073636254
Provider Name (Legal Business Name): TAYYEBEH LOGHMANI RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 04/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 N. RONALD REAGAN PKWY
AVON IN
46123-7085
US

IV. Provider business mailing address

250 N SHADELAND AVE SUITE 130
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-217-3384
  • Fax: 317-217-3386
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37000716A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: