MEDICARE: VIGEO KETAMINE AND WELLNESS CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center
2	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1912612557
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VIGEO KETAMINE AND WELLNESS CENTER, LLC

Provider Business Mailing Address
First Line	:	148 BEARCLAW CIR
Second Line	:
City	:	ALEDO
State	:	TX
Zip	:	76008-1230
Country	:	US
Telephone Number	:	817-886-4976
Fax Number	:

Provider Business Practice Location Address
First Line	:	1800 LONE OAK RD STE 10
Second Line	:
City	:	WEATHERFORD
State	:	TX
Zip	:	76086-4912
Country	:	US
Telephone Number	:	817-783-0463
Fax Number	:	682-262-1235

Authorized Official
Title or Position	:	OWNER/DIRECTOR
Name	:	MEGAN HOLLAND
Credential	:	CRNA
Telephone Number	:	817-886-4976

Provider Enumeration Date	:	01/18/2023
Last Update Date	:	01/05/2026

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