Healthcare Provider Details

I. General information

NPI: 1295257988
Provider Name (Legal Business Name): KETAMINE HEALTH & WELLNESS CENTER OF TEXAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5944 W PARKER RD STE 400
PLANO TX
75093-6443
US

IV. Provider business mailing address

5944 W PARKER RD STE 400
PLANO TX
75093-6443
US

V. Phone/Fax

Practice location:
  • Phone: 972-980-0500
  • Fax: 972-980-0503
Mailing address:
  • Phone: 972-980-0500
  • Fax: 972-980-0503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberL4969
License Number StateTX

VIII. Authorized Official

Name: MRS. LESLIE K HILL
Title or Position: BILLING MANAGER
Credential:
Phone: 972-980-0500