Provider Demographics
NPI:1912612557
Name:VIGEO KETAMINE AND WELLNESS CENTER, LLC
Entity type:Organization
Organization Name:VIGEO KETAMINE AND WELLNESS CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:817-886-4976
Mailing Address - Street 1:906 W CANNON ST APT 100
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3052
Mailing Address - Country:US
Mailing Address - Phone:817-886-4976
Mailing Address - Fax:
Practice Address - Street 1:1800 LONE OAK RD STE 10
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-4912
Practice Address - Country:US
Practice Address - Phone:817-783-0463
Practice Address - Fax:682-262-1235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-18
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty