Healthcare Provider Details

I. General information

NPI: 1942988613
Provider Name (Legal Business Name): KETAMINE CLINIC SOUTH FLORIDA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2023
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 N FEDERAL HWY STE A
POMPANO BEACH FL
33062-4304
US

IV. Provider business mailing address

41 N FEDERAL HWY STE A
POMPANO BEACH FL
33062-4304
US

V. Phone/Fax

Practice location:
  • Phone: 954-320-4944
  • Fax: 954-400-5805
Mailing address:
  • Phone: 954-320-4944
  • Fax: 954-400-5805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: KHALIUN CHULUUN REED
Title or Position: PARTNER
Credential: APRN
Phone: 305-331-7149