Provider Demographics
NPI:1225673643
Name:TEXAS KETAMINE SPECIALISTS
Entity Type:Organization
Organization Name:TEXAS KETAMINE SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:469-774-3069
Mailing Address - Street 1:12740 HILLCREST RD STE 295
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-7108
Mailing Address - Country:US
Mailing Address - Phone:469-774-3069
Mailing Address - Fax:
Practice Address - Street 1:12740 HILLCREST RD STE 295
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-7108
Practice Address - Country:US
Practice Address - Phone:469-774-3069
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-08
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty