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General NPI Number Information
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NPI Number | 1518587245
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Entity Type | Organization
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Legal Business Name | KETAMINE HEALTH CENTERS AT BONITA SPRINGS, LLC
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Dates
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Enumeration Date | 04/22/2020
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Last Update Date | 07/31/2023
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Provider Practice Location Address
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Address Line | 26800 S TAMIAMI TRL STE 310
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City | BONITA SPRINGS
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State | FL
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Zip | 34134-4348
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Country | US
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Telephone | 305-856-9442
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Fax |
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Provider Business Mailing Address
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Address Line | 1430 S DIXIE HWY STE 204
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City | CORAL GABLES
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State | FL
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Zip | 33146-3127
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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 | OWNER
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Name | DR. RAUL A CRUZ
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Credential | MD
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Telephone | 305-856-9442
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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