Provider Demographics
NPI:1114586138
Name:KETAMINE HOLISTIC WELLNESS CENTER, PLLC
Entity Type:Organization
Organization Name:KETAMINE HOLISTIC WELLNESS CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KYMBERLY
Authorized Official - Middle Name:TESH
Authorized Official - Last Name:PIERCE-DEW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-720-5448
Mailing Address - Street 1:1024 HIGHWAY A1A STE 152
Mailing Address - Street 2:
Mailing Address - City:SATELLITE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-2341
Mailing Address - Country:US
Mailing Address - Phone:321-777-8040
Mailing Address - Fax:321-821-0212
Practice Address - Street 1:1024 HIGHWAY A1A STE 152
Practice Address - Street 2:
Practice Address - City:SATELLITE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-2341
Practice Address - Country:US
Practice Address - Phone:321-777-8040
Practice Address - Fax:321-821-0212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty