Provider Demographics
NPI:1508425273
Name:FOUR CORNERS KETAMINE CENTER INC
Entity Type:Organization
Organization Name:FOUR CORNERS KETAMINE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CAPLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:970-828-3030
Mailing Address - Street 1:72 SUTTLE ST UNIT M
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81303-6829
Mailing Address - Country:US
Mailing Address - Phone:970-828-3030
Mailing Address - Fax:
Practice Address - Street 1:72 SUTTLE ST UNIT M
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81303-6829
Practice Address - Country:US
Practice Address - Phone:970-828-3030
Practice Address - Fax:970-247-0221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center