Provider Demographics
NPI:1225774326
Name:MGM KETAMINE SERVICES LLC
Entity Type:Organization
Organization Name:MGM KETAMINE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:MALINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-483-3760
Mailing Address - Street 1:59 GLENORCHY PL
Mailing Address - Street 2:
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10804-3512
Mailing Address - Country:US
Mailing Address - Phone:201-483-3760
Mailing Address - Fax:
Practice Address - Street 1:690 KINDERKAMACK RD STE 103
Practice Address - Street 2:
Practice Address - City:ORADELL
Practice Address - State:NJ
Practice Address - Zip Code:07649-1524
Practice Address - Country:US
Practice Address - Phone:201-483-3760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-11
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty