Provider Demographics
NPI:1508406588
Name:KETAMINE WELLNESS CENTERS CHICAGO
Entity Type:Organization
Organization Name:KETAMINE WELLNESS CENTERS CHICAGO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:D
Authorized Official - Last Name:JERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-538-9355
Mailing Address - Street 1:603 E DIEHL RD STE 139
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-4905
Mailing Address - Country:US
Mailing Address - Phone:855-538-9355
Mailing Address - Fax:844-538-9355
Practice Address - Street 1:603 E DIEHL RD
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-1452
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:2020-01-08
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty