Healthcare Provider Details

I. General information

NPI: 1316556020
Provider Name (Legal Business Name): KETAMINE NORTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2020
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 E CENTRAL ENTRANCE
DULUTH MN
55811-5501
US

IV. Provider business mailing address

1003 E CENTRAL ENTRANCE
DULUTH MN
55811-5501
US

V. Phone/Fax

Practice location:
  • Phone: 218-209-2150
  • Fax:
Mailing address:
  • Phone: 218-209-2150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NATALIE NICOLE JOHNSON
Title or Position: OWNER
Credential: CRNA
Phone: 507-398-6313