Provider Demographics
NPI:1063297711
Name:KENDRA'S KUSTOM NUTRITION
Entity type:Organization
Organization Name:KENDRA'S KUSTOM NUTRITION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIETITIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LD, CNSC
Authorized Official - Phone:816-408-9225
Mailing Address - Street 1:12411 LIVE OAK CIR
Mailing Address - Street 2:
Mailing Address - City:PECULIAR
Mailing Address - State:MO
Mailing Address - Zip Code:64078-2583
Mailing Address - Country:US
Mailing Address - Phone:816-408-9225
Mailing Address - Fax:
Practice Address - Street 1:12411 LIVE OAK CIR
Practice Address - Street 2:
Practice Address - City:PECULIAR
Practice Address - State:MO
Practice Address - Zip Code:64078-2583
Practice Address - Country:US
Practice Address - Phone:816-408-9225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
No253Z00000XAgenciesIn Home Supportive Care