MEDICARE: QUAD CITIES KETAMINE CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner

General Provider Information

NPI Number	:	1629781935
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUAD CITIES KETAMINE CLINIC

Provider Business Mailing Address
First Line	:	4622 PROGRESS DR STE A
Second Line	:
City	:	DAVENPORT
State	:	IA
Zip	:	52807-3426
Country	:	US
Telephone Number	:	563-214-1594
Fax Number	:	563-293-2803

Provider Business Practice Location Address
First Line	:	4626 PROGRESS DR STE A
Second Line	:
City	:	DAVENPORT
State	:	IA
Zip	:	52807-3485
Country	:	US
Telephone Number	:	563-214-1594
Fax Number	:	563-293-2803

Authorized Official
Title or Position	:	OWNER
Name	:	TARA M KINNEY
Credential	:	CRNA
Telephone Number	:	563-214-1594

Provider Enumeration Date	:	01/02/2023
Last Update Date	:	06/18/2026

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