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Prestige Ketamine PC

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Company Details

Name: Prestige Ketamine PC
Jurisdiction: Idaho
Legal type: Professional Service Corporation (D)
Status: Inactive-Dissolved (Administrative)
Date of registration: 15 Mar 2023 (2 years ago)
Financial Date End: 31 Mar 2024
Date dissolved: 12 Jun 2024
Entity Number: 5156532
Place of Formation: IDAHO
File Number: 868906
ZIP code: 83442
County: Jefferson County
Mailing Address: 3749 E 343 N RIGBY, ID 83442-5326

Agent

Name Role Address
Levi Hansen Agent 3749 E 343 N, RIGBY, ID 83442

National Provider Identifier

NPI Number:
1588353999
Certification Date:
2023-03-15

Authorized Person:

Name:
LEVI HANSEN
Role:
CEO
Phone:

Taxonomy:

Selected Taxonomy:
261QI0500X - Infusion Therapy Clinic/Center
Is Primary:
Yes

Contacts:

Filing

Filing Name Filing Number Filing date
Dissolution/Revocation - Administrative 0005777823 2024-06-12
Initial Filing 0005156532 2023-03-15

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Date of last update: 26 Mar 2025

Sources: Idaho Secretary of State