Healthcare Provider Details

I. General information

NPI: 1619744158
Provider Name (Legal Business Name): KETASCLEPIUS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2023
Last Update Date: 04/17/2024
Certification Date: 04/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 MCALPINE ST STE 6
AVOCA PA
18641-1104
US

IV. Provider business mailing address

824 MCALPINE ST STE 6
AVOCA PA
18641-1104
US

V. Phone/Fax

Practice location:
  • Phone: 570-701-6044
  • Fax:
Mailing address:
  • Phone: 570-701-6044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KELLY WILSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 727-517-6524