Provider Demographics
NPI:1386366532
Name:MODERN KETAMINE CLINIC
Entity type:Organization
Organization Name:MODERN KETAMINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:FALVEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:763-347-2100
Mailing Address - Street 1:13792 REIMER DR N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-2219
Mailing Address - Country:US
Mailing Address - Phone:763-347-2100
Mailing Address - Fax:763-333-7174
Practice Address - Street 1:13792 REIMER DR N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-2219
Practice Address - Country:US
Practice Address - Phone:763-347-2100
Practice Address - Fax:763-333-7174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-14
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty