Provider Demographics
NPI:1174300693
Name:PROSPER KETAMINE & IV NUTRITION THERAPY LLC
Entity type:Organization
Organization Name:PROSPER KETAMINE & IV NUTRITION THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BERCEY
Authorized Official - Middle Name:
Authorized Official - Last Name:NTOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-584-9905
Mailing Address - Street 1:1400 N COIT RD STE 1103
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75071-6659
Mailing Address - Country:US
Mailing Address - Phone:469-584-9905
Mailing Address - Fax:469-343-1998
Practice Address - Street 1:1400 N COIT RD STE 1103
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75071-6659
Practice Address - Country:US
Practice Address - Phone:469-584-9905
Practice Address - Fax:469-343-1998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-08
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty