Ketamine Wellness Centers Mesa, LLC

Primary specialty

Anesthesiology PhysicianTaxonomy code 207L00000X

Legal business name

KETAMINE WELLNESS CENTERS MESA, LLC

Practice address

2451 E Baseline Rd Ste 300
Gilbert, AZ 85234-2465

Phone

(480) 788-8539

Fax

(844) 538-9355

NPI assigned

Jun 26, 2019

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Ms. Anita D Jerger

Title

Executive Assistant

Phone

(855) 538-9355

Specialties & licenses 5

Addresses

Electronic endpoints 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1561507200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1641772800000",
    "number": "1447811898",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2451 E BASELINE RD STE 300",
            "city": "GILBERT",
            "state": "AZ",
            "postal_code": "852342465",
            "telephone_number": "480-788-8539",
            "fax_number": "844-538-9355"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2451 E BASELINE RD STE 300",
            "city": "GILBERT",
            "state": "AZ",
            "postal_code": "852342465",
            "telephone_number": "480-788-8539",
            "fax_number": "844-538-9355"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KETAMINE WELLNESS CENTERS MESA, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-06-26",
        "last_updated": "2022-01-10",
        "certification_date": "2021-09-21",
        "status": "A",
        "authorized_official_last_name": "JERGER",
        "authorized_official_first_name": "ANITA",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "EXECUTIVE ASSISTANT",
        "authorized_official_telephone_number": "855-538-9355",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "163W00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Registered Nurse",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207L00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Anesthesiology",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "208VP0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pain Medicine, Pain Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208VP0014X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pain Medicine, Interventional Pain Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "Mesa",
            "affiliation": "N",
            "address_1": "2152 S Vineyard Ste 131",
            "city": "Mesa",
            "state": "AZ",
            "country_code": "US",
            "postal_code": "852106882",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 10, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.