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General NPI Number Information
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NPI Number | 1174307615
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Entity Type | Organization
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Legal Business Name | CENTRE YOU KETAMINE LLC
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Dates
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Enumeration Date | 08/24/2023
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Last Update Date | 08/24/2023
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Provider Practice Location Address
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Address Line | 491 N FREEDOM BLVD
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City | PROVO
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State | UT
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Zip | 84601-2824
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Country | US
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Telephone | 844-236-8738
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Fax |
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Provider Business Mailing Address
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Address Line | 933 E 1910 S STE 102
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City | PROVO
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State | UT
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Zip | 84606-5562
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Country | US
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Telephone | 844-236-8738
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Fax | 833-671-0458
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Authorized Official
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Title or Position | MANAGER
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Name | JOHN BELL
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Credential |
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Telephone | 844-236-8738
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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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