Provider Demographics
NPI:1598235012
Name:KETAMINE CA PC
Entity Type:Organization
Organization Name:KETAMINE CA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:CHALLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAYCHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-344-9850
Mailing Address - Street 1:3724 N 3RD ST STE 201
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2034
Mailing Address - Country:US
Mailing Address - Phone:602-344-9850
Mailing Address - Fax:
Practice Address - Street 1:6313 SCHIRRA CT STE 1A
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93313-2174
Practice Address - Country:US
Practice Address - Phone:602-790-3744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-27
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy