Provider Demographics
NPI:1457918831
Name:KETAMINE WELLNESS CENTERS WASHINGTON
Entity Type:Organization
Organization Name:KETAMINE WELLNESS CENTERS WASHINGTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:D
Authorized Official - Last Name:JERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-538-9355
Mailing Address - Street 1:34709 9TH AVE S STE B200
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-8724
Mailing Address - Country:US
Mailing Address - Phone:855-538-9355
Mailing Address - Fax:844-538-9355
Practice Address - Street 1:34709 9TH AVE S STE B200
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-8724
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:2019-05-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty