Provider Demographics
NPI:1942988613
Name:KETAMINE CLINIC SOUTH FLORIDA
Entity Type:Organization
Organization Name:KETAMINE CLINIC SOUTH FLORIDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:KHALIUN
Authorized Official - Middle Name:CHULUUN
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:305-331-7149
Mailing Address - Street 1:41 N FEDERAL HWY STE A
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33062-4304
Mailing Address - Country:US
Mailing Address - Phone:954-320-4944
Mailing Address - Fax:954-400-5805
Practice Address - Street 1:41 N FEDERAL HWY STE A
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33062-4304
Practice Address - Country:US
Practice Address - Phone:954-320-4944
Practice Address - Fax:954-400-5805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, AdultGroup - Single Specialty