Healthcare Provider Details

I. General information

NPI: 1003408857
Provider Name (Legal Business Name): THE MINNESOTA KETAMINE AND WELLNESS INSTITUTE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2021
Last Update Date: 08/20/2021
Certification Date: 08/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9325 UPLAND LN N STE 370
MAPLE GROVE MN
55369-4463
US

IV. Provider business mailing address

9325 UPLAND LN N STE 370
MAPLE GROVE MN
55369-4463
US

V. Phone/Fax

Practice location:
  • Phone: 612-394-8717
  • Fax: 763-432-5721
Mailing address:
  • Phone: 612-394-8717
  • Fax: 763-432-5721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHRISTENA REGENA HATCHER
Title or Position: CFO
Credential: CRNA
Phone: 612-394-8717