Provider Demographics
NPI:1003529728
Name:KETAMINE WEST LLC
Entity Type:Organization
Organization Name:KETAMINE WEST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:STRYDER
Authorized Official - Middle Name:RIVER
Authorized Official - Last Name:REILLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-644-1279
Mailing Address - Street 1:602 26 1/2 RD
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-1905
Mailing Address - Country:US
Mailing Address - Phone:970-644-1279
Mailing Address - Fax:
Practice Address - Street 1:836 S TOWNSEND AVE STE A
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-4360
Practice Address - Country:US
Practice Address - Phone:970-200-8365
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-27
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)