Healthcare Provider Details

I. General information

NPI: 1710522875
Provider Name (Legal Business Name): UPSTATE KETAMINE CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2019
Last Update Date: 11/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 MONROE AVE STE 319
ROCHESTER NY
14618-4617
US

IV. Provider business mailing address

3300 MONROE AVE STE 319
ROCHESTER NY
14618-4617
US

V. Phone/Fax

Practice location:
  • Phone: 585-673-2319
  • Fax:
Mailing address:
  • Phone: 585-673-2319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY C LEATHERSICH
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 585-673-2319