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General NPI Number Information
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NPI Number | 1902381213
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Entity Type | Organization
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Legal Business Name | FULLY LIVING CLINIC
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Dates
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Enumeration Date | 10/02/2018
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Last Update Date | 03/03/2019
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Provider Practice Location Address
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Address Line | 6615 E PACIFIC COAST HWY STE 225
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City | LONG BEACH
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State | CA
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Zip | 90803-4216
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Country | US
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Telephone | 888-628-3789
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Fax |
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Provider Business Mailing Address
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Address Line | 6615 E PACIFIC COAST HWY STE 225
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City | LONG BEACH
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State | CA
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Zip | 90803-4216
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Country | US
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Telephone | 888-628-3789
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Fax |
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Authorized Official
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Title or Position | FOUNDER
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Name | ASHEENA LEE
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Credential | M.D.
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Telephone | 888-628-3789
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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