Provider Demographics
NPI:1043953235
Name:FUNCTIONAL MEDICINE AND PSYCHIATRY INC.
Entity type:Organization
Organization Name:FUNCTIONAL MEDICINE AND PSYCHIATRY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-449-7000
Mailing Address - Street 1:115 W CALIFORNIA BLVD UNIT 9001
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3005
Mailing Address - Country:US
Mailing Address - Phone:626-449-7000
Mailing Address - Fax:
Practice Address - Street 1:4358 CHEVY CHASE DR
Practice Address - Street 2:
Practice Address - City:LA CANADA FLINTRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91011-3203
Practice Address - Country:US
Practice Address - Phone:626-449-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-15
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1689618464OtherNPI