Provider Demographics
NPI:1528795317
Name:TEXARKANA KETAMINE CLINIC, PLLC
Entity type:Organization
Organization Name:TEXARKANA KETAMINE CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-306-0838
Mailing Address - Street 1:1724 GALLERIA OAKS DR
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-4649
Mailing Address - Country:US
Mailing Address - Phone:903-306-0838
Mailing Address - Fax:903-306-1286
Practice Address - Street 1:1724 GALLERIA OAKS DR
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-4649
Practice Address - Country:US
Practice Address - Phone:903-306-0838
Practice Address - Fax:903-306-1286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-02
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain