Healthcare Provider Details

I. General information

NPI: 1235820325
Provider Name (Legal Business Name): KETAMINE WELLNESS CENTER OF FLORIDA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2023
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N FEDERAL HWY STE 302
HALLANDALE BEACH FL
33009-4300
US

IV. Provider business mailing address

110 N FEDERAL HWY STE 302
HALLANDALE BEACH FL
33009-4300
US

V. Phone/Fax

Practice location:
  • Phone: 818-814-1323
  • Fax: 954-374-8908
Mailing address:
  • Phone: 954-251-2217
  • Fax: 954-374-8908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: RUDOLF BELL
Title or Position: MEMBER
Credential:
Phone: 954-367-6261