=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114563434
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KETAMINE TREATMENT CENTERS OF PRINCETON, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2019
-----------------------------------------------------
Last Update Date | 11/21/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1411 N FLAGLER DR STE 4700
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33401-3408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-566-8774
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 BUNN DR STE 304
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08540-1968
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-566-8774
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | STEVEN P. LEVINE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 609-651-4429
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------