MEDICARE: MS. BRENDA D BUSTILLOS MS, RD, LD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	DT80151	TX

General Provider Information

NPI Number	:	1689851628
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BRENDA D BUSTILLOS MS, RD, LD

Provider Business Mailing Address
First Line	:	PO BOX 131
Second Line	:
City	:	MEDICINE PARK
State	:	OK
Zip	:	73557-0131
Country	:	US
Telephone Number	:	580-458-3055
Fax Number	:	580-458-2846

Provider Business Practice Location Address
First Line	:	4301 MOW-WAY ROAD (MCUA-NCD)
Second Line	:	CDR USAMEDDAC
City	:	FORT SILL
State	:	OK
Zip	:	73503-6300
Country	:	US
Telephone Number	:	580-458-3055
Fax Number	:	580-458-2846

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/22/2008
Last Update Date	:	01/22/2008

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