Provider Demographics
NPI:1518587245
Name:KETAMINE HEALTH CENTERS AT BONITA SPRINGS, LLC
Entity Type:Organization
Organization Name:KETAMINE HEALTH CENTERS AT BONITA SPRINGS, LLC
Other - Org Name:KETAMINE HEALTH CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAUL
Authorized Official - Middle Name:A
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-856-9442
Mailing Address - Street 1:1430 S DIXIE HWY STE 204
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-3127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26800 S TAMIAMI TRL STE 310
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-4348
Practice Address - Country:US
Practice Address - Phone:305-856-9442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-22
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service