Provider Demographics
NPI:1629830005
Name:KETAMINE WELLNESS INFUSIONS PA LLC
Entity Type:Organization
Organization Name:KETAMINE WELLNESS INFUSIONS PA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:GABAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:484-434-8963
Mailing Address - Street 1:146 MONTGOMERY AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-2956
Mailing Address - Country:US
Mailing Address - Phone:484-434-8963
Mailing Address - Fax:
Practice Address - Street 1:146 MONTGOMERY AVE STE 202
Practice Address - Street 2:
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-2956
Practice Address - Country:US
Practice Address - Phone:484-434-9633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-30
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty