Provider Demographics
NPI:1861008831
Name:KETAMINE WELLNESS CENTERS HOUSTON
Entity Type:Organization
Organization Name:KETAMINE WELLNESS CENTERS HOUSTON
Other - Org Name:KETAMINE WELLNESS CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:JERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-538-9355
Mailing Address - Street 1:12807 HAYNES RD UNIT 1
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77066-1124
Mailing Address - Country:US
Mailing Address - Phone:855-538-9355
Mailing Address - Fax:844-538-9355
Practice Address - Street 1:12807 HAYNES RD UNIT 1
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77066-1124
Practice Address - Country:US
Practice Address - Phone:855-538-9355
Practice Address - Fax:844-538-9355
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KETAMINE WELLNESS CENTERS ARIZONA LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-16
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty