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NPI Code Detail

MEDICARE: KETAMINAMD LLC

MEDICARE: KETAMINAMD LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1251B00000XCase Management Agency

General Provider Information

NPI Number : 1063288686
Entity Type Code : Organization
Provider Name (Legal Business Name) : KETAMINAMD LLC
Provider Business Mailing Address
First Line : 930 S 4TH ST STE 209
Second Line :
City : LAS VEGAS
State : NV
Zip : 89101-6845
Country : US
Telephone Number : 929-494-1182
Fax Number : 929-494-1182
Provider Business Practice Location Address
First Line : 930 S 4TH ST STE 209
Second Line :
City : LAS VEGAS
State : NV
Zip : 89101-6845
Country : US
Telephone Number : 929-494-1182
Fax Number : 929-494-1182
Authorized Official
Title or Position : AUTHORIZING REPRESENTATIVE
Name : MATTHEW SESSA
Credential :
Telephone Number : 929-494-1182
Provider Enumeration Date : 11/27/2023
Last Update Date : 06/19/2024

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Directions to “KETAMINAMD LLC ” Practice Location

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