Provider Demographics
NPI:1710522875
Name:UPSTATE KETAMINE CARE
Entity Type:Organization
Organization Name:UPSTATE KETAMINE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:C
Authorized Official - Last Name:LEATHERSICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-673-2319
Mailing Address - Street 1:3300 MONROE AVE STE 319
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-4617
Mailing Address - Country:US
Mailing Address - Phone:585-673-2319
Mailing Address - Fax:
Practice Address - Street 1:3300 MONROE AVE STE 319
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-4617
Practice Address - Country:US
Practice Address - Phone:585-673-2319
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03426666Medicaid