Healthcare Provider Details

I. General information

NPI: 1356195192
Provider Name (Legal Business Name): JUSTIN BOLES CUDNIK RDN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2024
Last Update Date: 04/17/2024
Certification Date: 04/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 W 123RD ST
OVERLAND PARK KS
66209-3193
US

IV. Provider business mailing address

8809 LAMAR AVE
OVERLAND PARK KS
66207-2022
US

V. Phone/Fax

Practice location:
  • Phone: 913-317-2600
  • Fax:
Mailing address:
  • Phone: 785-979-9171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3043
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: