Healthcare Provider Details

I. General information

NPI: 1215741145
Provider Name (Legal Business Name): KEANU SHEELONG VUE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2025
Last Update Date: 02/03/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6255 N FRESNO ST STE 101
FRESNO CA
93710-5271
US

IV. Provider business mailing address

7034 E FEDORA AVE
FRESNO CA
93737-9219
US

V. Phone/Fax

Practice location:
  • Phone: 559-341-5034
  • Fax:
Mailing address:
  • Phone: 559-720-0857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: