MEDICARE: BODACIOUS NUTRITION LLC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124895024
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BODACIOUS NUTRITION LLC

Provider Business Mailing Address
First Line	:	2134 S NELSON ST
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22204-5410
Country	:	US
Telephone Number	:	804-787-4431
Fax Number	:

Provider Business Practice Location Address
First Line	:	2134 S NELSON ST
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22204-5410
Country	:	US
Telephone Number	:	804-787-4431
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JOANNA R PUSTILNIK
Credential	:	MS RDN CDCES
Telephone Number	:	804-787-4431

Provider Enumeration Date	:	12/11/2023
Last Update Date	:	12/11/2023

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