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General NPI Number Information
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NPI Number | 1124832431
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Entity Type | Organization
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Legal Business Name | LILAC NUTRITION LLC
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Dates
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Enumeration Date | 02/05/2025
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Last Update Date | 02/05/2025
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Provider Practice Location Address
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Address Line | 2 DUBON CT
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City | FARMINGDALE
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State | NY
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Zip | 11735-1031
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Country | US
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Telephone | 631-210-6362
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Fax |
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Provider Business Mailing Address
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Address Line | 712 OAK NECK RD
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City | WEST ISLIP
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State | NY
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Zip | 11795-3619
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Country | US
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Telephone | 631-210-6362
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KATIE DOWD
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Credential | NDTR, CLC
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Telephone | 631-774-1565
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 136A00000X
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Taxonomy Name | Registered Dietetic Technician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 174N00000X
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Taxonomy Name | Lactation Consultant (Non-RN)
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License Number |
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License Number State |
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