Provider Demographics
NPI:1912466004
Name:SUMMIT KETAMINE, PC
Entity Type:Organization
Organization Name:SUMMIT KETAMINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:COAKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:719-641-7614
Mailing Address - Street 1:2077 S CLARKSON ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-4105
Mailing Address - Country:US
Mailing Address - Phone:719-641-7614
Mailing Address - Fax:
Practice Address - Street 1:19284 COTTONWOOD DR STE 200
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80138-3881
Practice Address - Country:US
Practice Address - Phone:719-641-7614
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1578616413OtherPERSONAL NPI