Healthcare Provider Details

I. General information

NPI: 1629781935
Provider Name (Legal Business Name): QUAD CITIES KETAMINE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2023
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4626 PROGRESS DR STE A
DAVENPORT IA
52807-3485
US

IV. Provider business mailing address

4626 PROGRESS DR STE A
DAVENPORT IA
52807-3485
US

V. Phone/Fax

Practice location:
  • Phone: 563-214-1594
  • Fax: 563-293-2803
Mailing address:
  • Phone: 563-214-1594
  • Fax: 563-293-2803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TARA KINNEY
Title or Position: OWNER
Credential: CRNA, APRN
Phone: 507-254-9199