MEDICARE: KETAMINE WELLNESS INSTITUTE OF JACKSONVILLE BEACH, 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
1	208VP0014X	Interventional Pain Medicine Physician

General Provider Information

NPI Number	:	1487471918
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KETAMINE WELLNESS INSTITUTE OF JACKSONVILLE BEACH, LLC

Provider Business Mailing Address
First Line	:	1361 13TH AVE S STE 140
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-3263
Country	:	US
Telephone Number	:	904-373-8153
Fax Number	:

Provider Business Practice Location Address
First Line	:	1361 13TH AVE S STE 140
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-3263
Country	:	US
Telephone Number	:	904-373-8153
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SATHAVARAM REDDY
Credential	:	MD
Telephone Number	:	904-373-8153

Provider Enumeration Date	:	09/25/2024
Last Update Date	:	09/25/2024

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