Provider Demographics
NPI:1760282107
Name:FAMILY TABLE LLC
Entity type:Organization
Organization Name:FAMILY TABLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:AMES
Authorized Official - Last Name:HEINDEL
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:208-859-5028
Mailing Address - Street 1:6050 SUNRISE AVE
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-1533
Mailing Address - Country:US
Mailing Address - Phone:208-859-5028
Mailing Address - Fax:
Practice Address - Street 1:1005 E FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5951
Practice Address - Country:US
Practice Address - Phone:208-859-5028
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-14
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)