Provider Demographics
NPI:1487471918
Name:KETAMINE WELLNESS INSTITUTE OF JACKSONVILLE BEACH, LLC
Entity type:Organization
Organization Name:KETAMINE WELLNESS INSTITUTE OF JACKSONVILLE BEACH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SATHAVARAM
Authorized Official - Middle Name:
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-373-8153
Mailing Address - Street 1:1361 13TH AVE S STE 140
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-3263
Mailing Address - Country:US
Mailing Address - Phone:904-373-8153
Mailing Address - Fax:
Practice Address - Street 1:1361 13TH AVE S STE 140
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3263
Practice Address - Country:US
Practice Address - Phone:904-373-8153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty