Provider Demographics
NPI:1417404302
Name:ELLEN J MATHESON FUNCTIONAL WELLNESS SOLUTIONS, LLC
Entity Type:Organization
Organization Name:ELLEN J MATHESON FUNCTIONAL WELLNESS SOLUTIONS, LLC
Other - Org Name:ELJEMA WELLNESS
Other - Org Type:Other Name
Authorized Official - Title/Position:CERTIFIED NUTRITION SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MATHESON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CNS, LMT
Authorized Official - Phone:843-410-8567
Mailing Address - Street 1:2948 CATHEDRAL LN
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-7309
Mailing Address - Country:US
Mailing Address - Phone:843-324-5736
Mailing Address - Fax:
Practice Address - Street 1:621 WAPPOO RD
Practice Address - Street 2:SEED OF LIFE COLLECTIVE
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-1800
Practice Address - Country:US
Practice Address - Phone:843-410-8567
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty