Provider Demographics
NPI:1053132308
Name:KETAMINE CENTERS OF CENTRAL GEORGIA LLC
Entity type:Organization
Organization Name:KETAMINE CENTERS OF CENTRAL GEORGIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDAH
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-201-9220
Mailing Address - Street 1:6275 RIVOLI DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1456
Mailing Address - Country:US
Mailing Address - Phone:478-363-0016
Mailing Address - Fax:478-203-9322
Practice Address - Street 1:3312 NORTHSIDE DR STE D235
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-0426
Practice Address - Country:US
Practice Address - Phone:478-201-9220
Practice Address - Fax:478-203-9322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty