Provider Demographics
NPI:1902381213
Name:FULLY LIVING CLINIC
Entity Type:Organization
Organization Name:FULLY LIVING CLINIC
Other - Org Name:ASHEENA KEITH MEDICAL CORPORATION
Other - Org Type:Other Name
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:ASHEENA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:888-628-3789
Mailing Address - Street 1:6615 E PACIFIC COAST HWY STE 225
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-4216
Mailing Address - Country:US
Mailing Address - Phone:888-628-3789
Mailing Address - Fax:
Practice Address - Street 1:6615 E PACIFIC COAST HWY STE 225
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90803-4216
Practice Address - Country:US
Practice Address - Phone:888-628-3789
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-02
Last Update Date:2019-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty