Provider Demographics
NPI:1962156208
Name:LEE, ELIZA (RDN)
Entity type:Individual
Prefix:
First Name:ELIZA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:ELIZA
Other - Middle Name:LEE MIN XIAN
Other - Last Name:CHENG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RDN
Mailing Address - Street 1:1710 BARTON RD
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92373-5304
Mailing Address - Country:US
Mailing Address - Phone:909-307-4885
Mailing Address - Fax:
Practice Address - Street 1:1710 BARTON RD
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92373-5304
Practice Address - Country:US
Practice Address - Phone:909-307-4885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-06
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86209676133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty