Provider Demographics
NPI:1124895024
Name:BODACIOUS NUTRITION LLC
Entity type:Organization
Organization Name:BODACIOUS NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:R
Authorized Official - Last Name:PUSTILNIK
Authorized Official - Suffix:
Authorized Official - Credentials:MS RDN CDCES
Authorized Official - Phone:804-787-4431
Mailing Address - Street 1:2134 S NELSON ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22204-5410
Mailing Address - Country:US
Mailing Address - Phone:804-787-4431
Mailing Address - Fax:
Practice Address - Street 1:2134 S NELSON ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22204-5410
Practice Address - Country:US
Practice Address - Phone:804-787-4431
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1053842518Medicaid