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General NPI Number Information
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NPI Number | 1104611722
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Entity Type | Organization
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Legal Business Name | SOUTHERN KETAMINE AND WELLNESS, LLC
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Dates
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Enumeration Date | 04/14/2025
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Last Update Date | 04/14/2025
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Provider Practice Location Address
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Address Line | 2200 GATEWAY DR STE AA
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City | OPELIKA
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State | AL
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Zip | 36801-6884
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Country | US
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Telephone | 334-209-5340
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Fax |
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Provider Business Mailing Address
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Address Line | 1932 LAUREL RD STE 1B
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City | VESTAVIA HILLS
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State | AL
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Zip | 35216-1939
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | JOHN HARRISON IRONS
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Credential | MD
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Telephone | 205-379-6075
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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