Provider Demographics
NPI:1831595560
Name:TRACI BOLIN, RDN, LD LLC
Entity type:Organization
Organization Name:TRACI BOLIN, RDN, LD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:D
Authorized Official - Last Name:BOLIN
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, LD
Authorized Official - Phone:316-312-6388
Mailing Address - Street 1:14218 W BLUEGRASS CT
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67235-8065
Mailing Address - Country:US
Mailing Address - Phone:316-312-6388
Mailing Address - Fax:
Practice Address - Street 1:14218 W BLUEGRASS CT
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67235-8065
Practice Address - Country:US
Practice Address - Phone:316-312-6388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-06
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1966133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty