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General NPI Number Information
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NPI Number | 1255065504
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Entity Type | Organization
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Legal Business Name | NW KETAMINE INFUSION LLC
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Dates
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Enumeration Date | 07/12/2022
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Last Update Date | 07/12/2022
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Provider Practice Location Address
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Address Line | 19365 SW 65TH AVE STE 205
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City | TUALATIN
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State | OR
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Zip | 97062-9196
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Country | US
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Telephone | 503-427-0356
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Fax | 503-907-9255
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Provider Business Mailing Address
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Address Line | 19365 SW 65TH AVE STE 205
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City | TUALATIN
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State | OR
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Zip | 97062-9196
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Country | US
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Telephone | 503-427-0356
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Fax | 503-907-9255
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Authorized Official
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Title or Position | OWNER
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Name | MR. DAVID KLEIMAN
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Credential | CRNA
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Telephone | 323-687-6775
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number |
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License Number State | NULL
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