# GENESIS KETAMINE CENTERS

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1730886888
- **Authorized official:** MRS. KELLY SHAW (PRACTICE MANAGER)
- **Authorized official phone:** (267) 361-0315

## Contact information

- **Practice address:** 1 BALA AVE STE 418, BALA CYNWYD, PA 19004-3207
- **Practice address phone:** (267) 361-0315
- **Mailing address:** 1 BALA AVE STE 418, BALA CYNWYD, PA 19004-3207
- **Mailing address phone:** (267) 361-0315

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207L00000X | Anesthesiology Physician | — | NULL | Yes |
| 207L00000X | Anesthesiology Physician | — | — | Yes |
| 261QM1300X | Multi-Specialty Clinic/Center | — | NULL | — |

## Other

- **Enumeration date:** 02/09/2023
- **Last updated:** 02/09/2023