Provider Demographics
NPI:1598531659
Name:COMMUNAL TABLE WELLNESS, LLC
Entity Type:Organization
Organization Name:COMMUNAL TABLE WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD
Authorized Official - Phone:860-348-3281
Mailing Address - Street 1:1303 W VALENCIA DR # 278
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-4034
Mailing Address - Country:US
Mailing Address - Phone:860-348-3281
Mailing Address - Fax:
Practice Address - Street 1:601 W HOUSTON AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-3113
Practice Address - Country:US
Practice Address - Phone:860-348-3281
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-30
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty