Organization
PRESTIGE KETAMINE PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LEVI HANSEN (CEO)
(208) 705-9800
Entity
Organization
Contact information
Practice address
3749 E 343 N, RIGBY, ID 83442-5326
(208) 705-9800
Mailing address
3749 E 343 N, RIGBY, ID 83442-5326
(208) 705-9800
Taxonomy
Speciality
Code
Description
License number
State
261QI0500X
Infusion Therapy Clinic/Center
Primary
—
—
Other
Enumeration date
05/02/2023
Last updated
05/02/2023
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