Provider Demographics
NPI:1477362465
Name:KETAMINE FOR DEPRESSION SALT LAKE CITY LLC
Entity type:Organization
Organization Name:KETAMINE FOR DEPRESSION SALT LAKE CITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:NICOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:SALOMON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:385-474-6946
Mailing Address - Street 1:201 E 5900 S STE 200
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-5432
Mailing Address - Country:US
Mailing Address - Phone:385-474-6946
Mailing Address - Fax:385-355-2782
Practice Address - Street 1:201 E 5900 S STE 200
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5432
Practice Address - Country:US
Practice Address - Phone:385-474-6946
Practice Address - Fax:385-355-2782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-03
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty