MEDICARE: HOUSTON KETAMINE SPECIALISTS PLLC

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	261Q00000X	Clinic/Center
2	261QI0500X	Infusion Therapy Clinic/Center

General Provider Information

NPI Number	:	1649948449
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOUSTON KETAMINE SPECIALISTS PLLC

Provider Business Mailing Address
First Line	:	409 W JOHANNA ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78704-4235
Country	:	US
Telephone Number	:	303-818-8137
Fax Number	:	936-362-3319

Provider Business Practice Location Address
First Line	:	2510 S LOOP 336 W STE 115
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77304-3737
Country	:	US
Telephone Number	:	936-362-3319
Fax Number	:	936-362-3319

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. PAUL FOSTER
Credential	:	DO
Telephone Number	:	303-818-8137

Provider Enumeration Date	:	09/06/2021
Last Update Date	:	09/06/2021

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