{
"Npi": {
"NPI": "1124832431",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "LILAC NUTRITION LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "712 OAK NECK RD",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "WEST ISLIP",
"MailingAddressStateName": "NY",
"MailingAddressPostalCode": "11795-3619",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "631-210-6362",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "2 DUBON CT",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "FARMINGDALE",
"PracticeLocationAddressStateName": "NY",
"PracticeLocationAddressPostalCode": "11735-1031",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "631-210-6362",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "02/05/2025",
"LastUpdateDate": "02/05/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "DOWD",
"AuthorizedOfficialFirstName": "KATIE",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "OWNER",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "NDTR, CLC",
"AuthorizedOfficialTelephoneNumber": "631-774-1565",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "133V00000X",
"TaxonomyName": "Registered Dietitian",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "136A00000X",
"TaxonomyName": "Registered Dietetic Technician",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "174N00000X",
"TaxonomyName": "Lactation Consultant (Non-RN)",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": [
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
]
}
}
}