Provider Demographics
NPI:1477935369
Name:KETAMINE WELLNESS CENTERS ARIZONA LLC
Entity Type:Organization
Organization Name:KETAMINE WELLNESS CENTERS ARIZONA LLC
Other - Org Name:KETAMINE WELLNESS CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:JERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-538-9355
Mailing Address - Street 1:113 W HOOVER AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-5214
Mailing Address - Country:US
Mailing Address - Phone:855-538-9355
Mailing Address - Fax:844-538-9355
Practice Address - Street 1:113 W HOOVER AVE STE 101
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-5214
Practice Address - Country:US
Practice Address - Phone:855-538-9355
Practice Address - Fax:844-538-9355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-26
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty