=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720866916
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KETAMINE CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2023
-----------------------------------------------------
Last Update Date | 11/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 232 BOSTON POST RD STE 13
-----------------------------------------------------
City | MILFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06460-3158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-701-6388
-----------------------------------------------------
Fax | 203-306-3134
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 232 BOSTON POST RD STE 13
-----------------------------------------------------
City | MILFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06460-3158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-701-6388
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | AL GENE EJUSA ANG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 860-552-7592
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------