Provider Demographics
NPI:1649162439
Name:KETAVITA WELLNESS CLINIC
Entity type:Organization
Organization Name:KETAVITA WELLNESS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MEHDI
Authorized Official - Middle Name:
Authorized Official - Last Name:POURIA
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:925-565-8498
Mailing Address - Street 1:46 W WILDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SADDLE RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07458-2512
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:365 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:WYCKOFF
Practice Address - State:NJ
Practice Address - Zip Code:07481-1971
Practice Address - Country:US
Practice Address - Phone:925-565-8498
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-16
Last Update Date:2025-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center