Provider Demographics
NPI:1649738865
Name:KETAMINE OK LLC
Entity Type:Organization
Organization Name:KETAMINE OK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DUDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-703-0937
Mailing Address - Street 1:1105 SW 30TH CT
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-2887
Mailing Address - Country:US
Mailing Address - Phone:405-703-0937
Mailing Address - Fax:405-378-2776
Practice Address - Street 1:1105 SW 30TH CT
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-2887
Practice Address - Country:US
Practice Address - Phone:405-703-0937
Practice Address - Fax:405-378-2776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty