Basic Information
| Provider Information | |||||||||
| NPI: | 1255937439 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ARIZONA KETAMINE SPECIALISTS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 39179 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850699179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023950718 | ||||||||
| FaxNumber: | 6022778146 | ||||||||
| Practice Location | |||||||||
| Address1: | 18205 N 51ST AVE STE 105 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853081491 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6236888531 | ||||||||
| FaxNumber: | 6022778146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2020 | ||||||||
| LastUpdateDate: | 12/11/2020 | ||||||||
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| AuthorizedOfficialLastName: | VANLIROP | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4804149986 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 12/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 261QI0500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Infusion Therapy |
No ID Information.