Provider Demographics
NPI:1124348610
Name:LYNN P HILLERY/LIVE WELL WITH LYNN
Entity type:Organization
Organization Name:LYNN P HILLERY/LIVE WELL WITH LYNN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:P
Authorized Official - Last Name:HILLERY
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:631-921-1100
Mailing Address - Street 1:25 ANDREA LN
Mailing Address - Street 2:
Mailing Address - City:WEST SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11796-1515
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:76 SOUTHAVEN AVE
Practice Address - Street 2:STE 2
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-3745
Practice Address - Country:US
Practice Address - Phone:631-343-2024
Practice Address - Fax:631-343-2024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-07
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006087-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400021956Medicare PIN