Healthcare Provider Details

I. General information

NPI: 1548630395
Provider Name (Legal Business Name): THE IDEAL U, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2015
Last Update Date: 10/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

344 FULLER RD
ALBANY NY
12203-3647
US

IV. Provider business mailing address

344 FULLER RD
ALBANY NY
12203-3647
US

V. Phone/Fax

Practice location:
  • Phone: 518-512-5171
  • Fax:
Mailing address:
  • Phone: 518-512-5171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number21420118
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number21420118
License Number StateNY

VIII. Authorized Official

Name: ANDREA N LILLEY
Title or Position: PRACTITIONER/OWNER
Credential: MS, RN, CDE
Phone: 518-512-5171