Provider Demographics
NPI:1407406697
Name:NEW LIFE KETAMINE CLINIC LLC
Entity Type:Organization
Organization Name:NEW LIFE KETAMINE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:KLENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-689-5994
Mailing Address - Street 1:7905 SCHATZ POINTE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-3856
Mailing Address - Country:US
Mailing Address - Phone:937-554-5994
Mailing Address - Fax:
Practice Address - Street 1:7905 SCHATZ POINTE DR STE 100
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-3856
Practice Address - Country:US
Practice Address - Phone:937-545-5994
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-19
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty