Provider Demographics
NPI:1235724147
Name:VITASUITE IV & KETAMINE THERAPY
Entity Type:Organization
Organization Name:VITASUITE IV & KETAMINE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PART OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:
Authorized Official - Last Name:PETROS
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:712-775-2434
Mailing Address - Street 1:509 N ADAMS ST STE 2
Mailing Address - Street 2:
Mailing Address - City:CARROLL
Mailing Address - State:IA
Mailing Address - Zip Code:51401-2767
Mailing Address - Country:US
Mailing Address - Phone:712-775-2434
Mailing Address - Fax:712-775-2534
Practice Address - Street 1:509 N ADAMS ST STE 2
Practice Address - Street 2:
Practice Address - City:CARROLL
Practice Address - State:IA
Practice Address - Zip Code:51401-2767
Practice Address - Country:US
Practice Address - Phone:712-775-2434
Practice Address - Fax:712-775-2534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-02
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy