Provider Demographics
NPI:1154894616
Name:KETAMINE CLINICS LLC
Entity type:Organization
Organization Name:KETAMINE CLINICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:HERBERT
Authorized Official - Last Name:MANDEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-270-0625
Mailing Address - Street 1:6801 PARK TER STE 525
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-1543
Mailing Address - Country:US
Mailing Address - Phone:310-270-0625
Mailing Address - Fax:310-730-5993
Practice Address - Street 1:6801 PARK TER STE 525
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-1543
Practice Address - Country:US
Practice Address - Phone:310-270-0625
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical