Provider Demographics
NPI:1205598398
Name:SUNRISE KETAMINE CLINIC LLC
Entity type:Organization
Organization Name:SUNRISE KETAMINE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:MERKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:208-520-0527
Mailing Address - Street 1:3555 POTOMAC WAY STE B
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-4985
Mailing Address - Country:US
Mailing Address - Phone:208-524-9080
Mailing Address - Fax:208-529-3786
Practice Address - Street 1:3555 POTOMAC WAY STE B
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-4985
Practice Address - Country:US
Practice Address - Phone:208-524-9080
Practice Address - Fax:208-529-3786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty