Healthcare Provider Details

I. General information

NPI: 1235724147
Provider Name (Legal Business Name): VITASUITE IV & KETAMINE THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2021
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 N ADAMS ST STE 2
CARROLL IA
51401-2767
US

IV. Provider business mailing address

509 N ADAMS ST STE 2
CARROLL IA
51401-2767
US

V. Phone/Fax

Practice location:
  • Phone: 712-775-2434
  • Fax: 712-775-2534
Mailing address:
  • Phone: 712-775-2434
  • Fax: 712-775-2534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RUTH PETROS
Title or Position: PART OWNER
Credential: CRNA
Phone: 712-775-2434