1053132308 NPI number — KETAMINE CENTERS OF CENTRAL GEORGIA LLC

Table of content: (NPI 1053132308)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053132308 NPI number — KETAMINE CENTERS OF CENTRAL GEORGIA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KETAMINE CENTERS OF CENTRAL GEORGIA LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053132308
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6275 RIVOLI DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MACON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31210-1456
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-363-0016
Provider Business Mailing Address Fax Number:
478-203-9322

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3312 NORTHSIDE DR STE D235
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MACON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31210-0426
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-201-9220
Provider Business Practice Location Address Fax Number:
478-203-9322
Provider Enumeration Date:
10/21/2024

Additional Information

Authorized Official

Authorized Official Last Name:
GREENBERG
Authorized Official First Name:
JUDAH
Authorized Official Middle Name:
Authorized Official Title or Position:
DOCTOR OWNER
Authorized Official Telephone Number:
478-201-9220

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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