Healthcare Provider Details

I. General information

NPI: 1477780641
Provider Name (Legal Business Name): HEATHER BUSBY RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 06/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 WILD IRIS CT
COLUMBIA SC
29209-5734
US

IV. Provider business mailing address

29 WILD IRIS CT
COLUMBIA SC
29209-5734
US

V. Phone/Fax

Practice location:
  • Phone: 803-673-7661
  • Fax: 803-531-2060
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number18
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: