Provider Demographics
NPI:1063288686
Name:KETAMINAMD LLC
Entity type:Organization
Organization Name:KETAMINAMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZING REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:SESSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:929-494-1182
Mailing Address - Street 1:930 S 4TH ST STE 209
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89101-6845
Mailing Address - Country:US
Mailing Address - Phone:929-494-1182
Mailing Address - Fax:929-494-1182
Practice Address - Street 1:930 S 4TH ST STE 209
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89101-6845
Practice Address - Country:US
Practice Address - Phone:929-494-1182
Practice Address - Fax:929-494-1182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-27
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management