Provider Demographics
NPI:1518556075
Name:RENEWED WELLNESS AND KETAMINE CLINIC
Entity Type:Organization
Organization Name:RENEWED WELLNESS AND KETAMINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SADIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BECHER
Authorized Official - Suffix:
Authorized Official - Credentials:MS, APRN-CRNA
Authorized Official - Phone:701-866-6041
Mailing Address - Street 1:3441 45TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8970
Mailing Address - Country:US
Mailing Address - Phone:701-526-6960
Mailing Address - Fax:
Practice Address - Street 1:3441 45TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8970
Practice Address - Country:US
Practice Address - Phone:701-526-6960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center