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General NPI Number Information
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NPI Number | 1255937439
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Entity Type | Organization
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Legal Business Name | ARIZONA KETAMINE SPECIALISTS LLC
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Dates
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Enumeration Date | 12/11/2020
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Last Update Date | 12/11/2020
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Provider Practice Location Address
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Address Line | 18205 N 51ST AVE STE 105
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City | GLENDALE
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State | AZ
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Zip | 85308-1491
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Country | US
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Telephone | 623-688-8531
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Fax | 602-277-8146
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Provider Business Mailing Address
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Address Line | PO BOX 39179
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City | PHOENIX
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State | AZ
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Zip | 85069-9179
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Country | US
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Telephone | 602-395-0718
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Fax | 602-277-8146
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Authorized Official
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Title or Position | MANAGER
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Name | DAVID VANLIROP
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Credential | MD
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Telephone | 480-414-9986
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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Taxonomy #2
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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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