Healthcare Provider Details

I. General information

NPI: 1477935369
Provider Name (Legal Business Name): KETAMINE WELLNESS CENTERS ARIZONA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2015
Last Update Date: 08/21/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 W HOOVER AVE STE 101
MESA AZ
85210-5214
US

IV. Provider business mailing address

113 W HOOVER AVE STE 101
MESA AZ
85210-5214
US

V. Phone/Fax

Practice location:
  • Phone: 855-538-9355
  • Fax: 844-538-9355
Mailing address:
  • Phone: 855-538-9355
  • Fax: 844-538-9355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ANITA JERGER
Title or Position: EXECUTIVE ASSISTANT
Credential:
Phone: 855-538-9355