Healthcare Provider Details

I. General information

NPI: 1255065504
Provider Name (Legal Business Name): NW KETAMINE INFUSION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 07/12/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19365 SW 65TH AVE STE 205
TUALATIN OR
97062-9196
US

IV. Provider business mailing address

19365 SW 65TH AVE STE 205
TUALATIN OR
97062-9196
US

V. Phone/Fax

Practice location:
  • Phone: 503-427-0356
  • Fax: 503-907-9255
Mailing address:
  • Phone: 503-427-0356
  • Fax: 503-907-9255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. DAVID KLEIMAN
Title or Position: OWNER
Credential: CRNA
Phone: 323-687-6775