Provider Demographics
NPI:1740066216
Name:KETAMINE WELLNESS INSTITUTE, LLC
Entity type:Organization
Organization Name:KETAMINE WELLNESS INSTITUTE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BILAL
Authorized Official - Middle Name:
Authorized Official - Last Name:LATEEF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-943-9122
Mailing Address - Street 1:1335 CAPPOQUIN WAY
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-9396
Mailing Address - Country:US
Mailing Address - Phone:907-885-0206
Mailing Address - Fax:907-600-5089
Practice Address - Street 1:5915 FARRINGTON RD STE 105
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27517-9900
Practice Address - Country:US
Practice Address - Phone:907-885-0206
Practice Address - Fax:907-600-5089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-31
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty