MEDICARE: KETAMINE UPLIFT INC.

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1942156955
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KETAMINE UPLIFT INC.

Provider Business Mailing Address
First Line	:	3111 VIA DOLCE APT 506
Second Line	:
City	:	MARINA DEL REY
State	:	CA
Zip	:	90292-5077
Country	:	US
Telephone Number	:	310-965-6666
Fax Number	:	310-929-8436

Provider Business Practice Location Address
First Line	:	4640 ADMIRALTY WAY # 718A
Second Line	:
City	:	MARINA DEL REY
State	:	CA
Zip	:	90292-6621
Country	:	US
Telephone Number	:	310-280-4440
Fax Number	:	310-929-8436

Authorized Official
Title or Position	:	PRESIDENT/OWNER/MEDICAL DIRECTOR
Name	:	DR. GEOFFERY ALAN O'NEILL
Credential	:	MD
Telephone Number	:	310-965-6666

Provider Enumeration Date	:	03/10/2026
Last Update Date	:	03/10/2026

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