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General NPI Number Information
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NPI Number | 1003408857
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Entity Type | Organization
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Legal Business Name | THE MINNESOTA KETAMINE AND WELLNESS INSTITUTE PA
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Dates
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Enumeration Date | 02/03/2021
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Last Update Date | 08/20/2021
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Provider Practice Location Address
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Address Line | 9325 UPLAND LN N STE 370
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City | MAPLE GROVE
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State | MN
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Zip | 55369-4463
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Country | US
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Telephone | 612-394-8717
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Fax | 763-432-5721
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Provider Business Mailing Address
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Address Line | 9325 UPLAND LN N STE 370
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City | MAPLE GROVE
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State | MN
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Zip | 55369-4463
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Country | US
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Telephone | 612-394-8717
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Fax | 763-432-5721
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Authorized Official
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Title or Position | CFO
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Name | CHRISTENA REGENA HATCHER
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Credential | CRNA
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Telephone | 612-394-8717
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QI0500X
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Taxonomy Name | Infusion Therapy Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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Taxonomy #3
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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Taxonomy #4
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number |
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License Number State |
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