Provider Demographics
NPI:1447811898
Name:KETAMINE WELLNESS CENTERS MESA, LLC
Entity type:Organization
Organization Name:KETAMINE WELLNESS CENTERS MESA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:D
Authorized Official - Last Name:JERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-538-9355
Mailing Address - Street 1:2451 E BASELINE RD STE 300
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2465
Mailing Address - Country:US
Mailing Address - Phone:480-788-8539
Mailing Address - Fax:844-538-9355
Practice Address - Street 1:2451 E BASELINE RD STE 300
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2465
Practice Address - Country:US
Practice Address - Phone:480-788-8539
Practice Address - Fax:844-538-9355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-26
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty