Healthcare Provider Details

I. General information

NPI: 1376229393
Provider Name (Legal Business Name): VICTORIA BURGESS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2023
Last Update Date: 06/26/2023
Certification Date: 06/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BALINT DR APT 669
YONKERS NY
10710-3914
US

IV. Provider business mailing address

1 BALINT DR APT 669
YONKERS NY
10710-3914
US

V. Phone/Fax

Practice location:
  • Phone: 917-887-8006
  • Fax:
Mailing address:
  • Phone: 917-887-8006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1101X
TaxonomyGerontological Nutrition Registered Dietitian
License Number010934-01
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number010934-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: