Provider Demographics
NPI:1720866916
Name:KETAMINE CENTER LLC
Entity type:Organization
Organization Name:KETAMINE CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AL GENE
Authorized Official - Middle Name:EJUSA
Authorized Official - Last Name:ANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-552-7592
Mailing Address - Street 1:232 BOSTON POST RD STE 13
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-3158
Mailing Address - Country:US
Mailing Address - Phone:203-701-6388
Mailing Address - Fax:
Practice Address - Street 1:232 BOSTON POST RD STE 13
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-3158
Practice Address - Country:US
Practice Address - Phone:203-701-6388
Practice Address - Fax:203-306-3134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-19
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)