Healthcare Provider Details

I. General information

NPI: 1871218107
Provider Name (Legal Business Name): VICTORIA R BUDD RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VICTORIA R MOORE

II. Dates (important events)

Enumeration Date: 10/10/2022
Last Update Date: 04/02/2024
Certification Date: 04/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 E WASHINGTON ST STE A
INDIANAPOLIS IN
46204-2609
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-944-3500
  • Fax: 317-962-2474
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37003571A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number37003571A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: