Healthcare Provider Details

I. General information

NPI: 1124832431
Provider Name (Legal Business Name): LILAC NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2025
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 DUBON CT
FARMINGDALE NY
11735-1031
US

IV. Provider business mailing address

712 OAK NECK RD
WEST ISLIP NY
11795-3619
US

V. Phone/Fax

Practice location:
  • Phone: 631-210-6362
  • Fax:
Mailing address:
  • Phone: 631-210-6362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State

VIII. Authorized Official

Name: KATIE DOWD
Title or Position: OWNER
Credential: NDTR, CLC
Phone: 631-774-1565