Provider Demographics
NPI:1558871509
Name:KETAMINE CLINIC OF NORTH TEXAS, LLC
Entity Type:Organization
Organization Name:KETAMINE CLINIC OF NORTH TEXAS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:CARRUTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-929-9875
Mailing Address - Street 1:4100 FAIRWAY DR STE 200
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-6527
Mailing Address - Country:US
Mailing Address - Phone:214-929-9875
Mailing Address - Fax:
Practice Address - Street 1:4100 FAIRWAY DR STE 200
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-6527
Practice Address - Country:US
Practice Address - Phone:214-929-9875
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9284207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty