MEDICARE: MODERN KETAMINE CLINIC

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
1	261QM1300X	Multi-Specialty Clinic/Center
2	261QI0500X	Infusion Therapy Clinic/Center

General Provider Information

NPI Number	:	1386366532
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN KETAMINE CLINIC

Provider Business Mailing Address
First Line	:	13792 REIMER DR N
Second Line	:
City	:	MAPLE GROVE
State	:	MN
Zip	:	55311-2219
Country	:	US
Telephone Number	:	763-347-2100
Fax Number	:	763-333-7174

Provider Business Practice Location Address
First Line	:	13792 REIMER DR N
Second Line	:
City	:	MAPLE GROVE
State	:	MN
Zip	:	55311-2219
Country	:	US
Telephone Number	:	763-347-2100
Fax Number	:	763-333-7174

Authorized Official
Title or Position	:	MD
Name	:	DANIEL GREGORY FALVEY
Credential	:	MD
Telephone Number	:	763-347-2100

Provider Enumeration Date	:	09/14/2022
Last Update Date	:	05/28/2025

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