Provider Demographics
NPI:1669005336
Name:CLINIC KETAMINE PC
Entity Type:Organization
Organization Name:CLINIC KETAMINE PC
Other - Org Name:COMPREHENSIVE PAIN MANAGEMENT SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:KIPPLE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, MS, CRNA
Authorized Official - Phone:800-664-1539
Mailing Address - Street 1:1121 RIVER WOOD
Mailing Address - Street 2:
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78155-0083
Mailing Address - Country:US
Mailing Address - Phone:800-664-1539
Mailing Address - Fax:307-448-4666
Practice Address - Street 1:4920 NE STALLINGS DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1254
Practice Address - Country:US
Practice Address - Phone:936-569-9481
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-20
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty