Healthcare Provider Details

I. General information

NPI: 1023431988
Provider Name (Legal Business Name): LIPID (AKA)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2014
Last Update Date: 01/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 BEVERLY RD
HUNTINGTON STATION NY
11746-4522
US

IV. Provider business mailing address

153 BEVERLY RD
HUNTINGTON STATION NY
11746-4522
US

V. Phone/Fax

Practice location:
  • Phone: 631-425-1578
  • Fax: 631-425-1578
Mailing address:
  • Phone: 631-425-1578
  • Fax: 631-425-1578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number002667-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number002667-1
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number002667-1
License Number StateNY

VIII. Authorized Official

Name: MS. CARYN NISTICO
Title or Position: PRESIDENT/CONSULTING REG DIETITIAN
Credential: MS,RDN,CDN
Phone: 631-425-1578