Healthcare Provider Details

I. General information

NPI: 1679053680
Provider Name (Legal Business Name): ELISE LIU MPH, RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2018
Last Update Date: 08/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11070 STRATHMORE DR APT 1
LOS ANGELES CA
90024-2341
US

IV. Provider business mailing address

11070 STRATHMORE DR APT 1
LOS ANGELES CA
90024-2341
US

V. Phone/Fax

Practice location:
  • Phone: 415-887-8972
  • Fax:
Mailing address:
  • Phone: 415-887-8972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86056939
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: