Provider Demographics
NPI:1467003277
Name:SOUTHWEST KETAMINE TREATMENT CENTERS, PLLC
Entity Type:Organization
Organization Name:SOUTHWEST KETAMINE TREATMENT CENTERS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:DELILLO
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, CRNA, NSPM-C
Authorized Official - Phone:817-966-2762
Mailing Address - Street 1:1800 SABLE BAY LN
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76005-1304
Mailing Address - Country:US
Mailing Address - Phone:817-966-2762
Mailing Address - Fax:
Practice Address - Street 1:220 O CONNOR RIDGE BLVD STE 105
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-6573
Practice Address - Country:US
Practice Address - Phone:214-560-2000
Practice Address - Fax:214-560-2555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-23
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty