Provider Demographics
NPI:1851065676
Name:VIRGINIA BEACH KETAMINE & WELLNESS
Entity Type:Organization
Organization Name:VIRGINIA BEACH KETAMINE & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA, NP
Authorized Official - Phone:757-412-7030
Mailing Address - Street 1:1856 COLONIAL MEDICAL CT STE D
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-3075
Mailing Address - Country:US
Mailing Address - Phone:757-751-0800
Mailing Address - Fax:
Practice Address - Street 1:1856 COLONIAL MEDICAL CT STE D
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-3075
Practice Address - Country:US
Practice Address - Phone:757-751-0800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center