Healthcare Provider Details

I. General information

NPI: 1699522425
Provider Name (Legal Business Name): KETAMINE TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2024
Last Update Date: 05/14/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6921-6923 ALABAMA AVE
CANOGA PARK CA
91303
US

IV. Provider business mailing address

5985 TOPANGA CANYON BLVD
WOODLAND HILLS CA
91367-3623
US

V. Phone/Fax

Practice location:
  • Phone: 818-274-4609
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number
License Number State

VIII. Authorized Official

Name: JASON MIRSHOJAE
Title or Position: EMPLOYEE
Credential:
Phone: 818-606-2319