Provider Demographics
NPI:1356099154
Name:CORRIDOR KETAMINE LLC
Entity type:Organization
Organization Name:CORRIDOR KETAMINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/A.O
Authorized Official - Prefix:MR
Authorized Official - First Name:TRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:SASSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:703-447-5790
Mailing Address - Street 1:1900 JAMES ST STE 1
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-1895
Mailing Address - Country:US
Mailing Address - Phone:319-337-8329
Mailing Address - Fax:319-337-8692
Practice Address - Street 1:1900 JAMES ST STE 1
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-1895
Practice Address - Country:US
Practice Address - Phone:319-337-8329
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-11
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty