Organization
LAS VEGAS KETAMINE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ADAM C FISHER (OWNER/MANAGER)
(229) 412-5844
Entity
Organization
Contact information
Practice address
3650 N RANCHO DR STE 110, LAS VEGAS, NV 89130-3151
(702) 957-0468
Mailing address
5519 BRUIN LAKES ST, LAS VEGAS, NV 89131-5921
(229) 412-5844
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
—
—
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1407158694
TRICARE WEST
—
Enumeration date
11/17/2022
Last updated
03/06/2025
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