Provider Demographics
NPI:1568050052
Name:AFFORDABLE KETAMINE CLINICS, LLC
Entity Type:Organization
Organization Name:AFFORDABLE KETAMINE CLINICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROYCE
Authorized Official - Middle Name:B
Authorized Official - Last Name:BARTHOLOMEW
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:801-372-1888
Mailing Address - Street 1:375 N MAIN ST STE 202
Mailing Address - Street 2:
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037-1278
Mailing Address - Country:US
Mailing Address - Phone:801-450-7147
Mailing Address - Fax:385-209-2975
Practice Address - Street 1:375 N MAIN ST STE 202
Practice Address - Street 2:
Practice Address - City:KAYSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84037-1278
Practice Address - Country:US
Practice Address - Phone:801-450-7147
Practice Address - Fax:385-209-2975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-09
Last Update Date:2021-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528884092034Medicaid