Provider Demographics
NPI:1780461582
Name:KETAMINE HEALTH & RESTORATION, LLC.
Entity type:Organization
Organization Name:KETAMINE HEALTH & RESTORATION, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-298-8267
Mailing Address - Street 1:585 MAIN ST STE 145
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-4354
Mailing Address - Country:US
Mailing Address - Phone:301-298-8267
Mailing Address - Fax:301-517-9386
Practice Address - Street 1:585 MAIN ST STE 145
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-4354
Practice Address - Country:US
Practice Address - Phone:301-298-8267
Practice Address - Fax:301-517-9386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-13
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty