Provider Demographics
NPI:1003408857
Name:THE MINNESOTA KETAMINE AND WELLNESS INSTITUTE PA
Entity Type:Organization
Organization Name:THE MINNESOTA KETAMINE AND WELLNESS INSTITUTE PA
Other - Org Name:THE MINNESOTA KETAMINE AND WELLNESS INSTITUE, P.A.
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTENA
Authorized Official - Middle Name:REGENA
Authorized Official - Last Name:HATCHER
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:612-394-8717
Mailing Address - Street 1:9325 UPLAND LN N STE 370
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4463
Mailing Address - Country:US
Mailing Address - Phone:612-394-8717
Mailing Address - Fax:763-432-5721
Practice Address - Street 1:9325 UPLAND LN N STE 370
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4463
Practice Address - Country:US
Practice Address - Phone:612-394-8717
Practice Address - Fax:763-432-5721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-03
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty