Provider Demographics
NPI:1700590007
Name:SOUTHERN KETAMINE AND WELLNESS LLC
Entity Type:Organization
Organization Name:SOUTHERN KETAMINE AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:HARRISON
Authorized Official - Last Name:IRONS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-202-9163
Mailing Address - Street 1:1932 LAUREL RD STE 1B
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA HILLS
Mailing Address - State:AL
Mailing Address - Zip Code:35216-1939
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1932 LAUREL RD STE 1B
Practice Address - Street 2:
Practice Address - City:VESTAVIA HILLS
Practice Address - State:AL
Practice Address - Zip Code:35216-1939
Practice Address - Country:US
Practice Address - Phone:205-202-9163
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-11
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty