Provider Demographics
NPI:1265195812
Name:KETAMINE123LLC
Entity type:Organization
Organization Name:KETAMINE123LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:
Authorized Official - Last Name:FLETCHER
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:615-300-3096
Mailing Address - Street 1:3450 E FLETCHER AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-4659
Mailing Address - Country:US
Mailing Address - Phone:813-632-3223
Mailing Address - Fax:813-632-3224
Practice Address - Street 1:3450 E FLETCHER AVE STE 300
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4659
Practice Address - Country:US
Practice Address - Phone:813-632-3223
Practice Address - Fax:813-632-3224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-20
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty