Provider Demographics
NPI:1255065504
Name:NW KETAMINE INFUSION LLC
Entity type:Organization
Organization Name:NW KETAMINE INFUSION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEIMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:323-687-6775
Mailing Address - Street 1:19365 SW 65TH AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-9196
Mailing Address - Country:US
Mailing Address - Phone:503-427-0356
Mailing Address - Fax:503-907-9255
Practice Address - Street 1:19365 SW 65TH AVE STE 205
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-9196
Practice Address - Country:US
Practice Address - Phone:503-427-0356
Practice Address - Fax:503-907-9255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty