Provider Demographics
NPI:1619744158
Name:KETASCLEPIUS LLC
Entity Type:Organization
Organization Name:KETASCLEPIUS LLC
Other - Org Name:THE GOOD DROP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-517-6524
Mailing Address - Street 1:824 MCALPINE ST STE 6
Mailing Address - Street 2:
Mailing Address - City:AVOCA
Mailing Address - State:PA
Mailing Address - Zip Code:18641-1104
Mailing Address - Country:US
Mailing Address - Phone:570-701-6044
Mailing Address - Fax:
Practice Address - Street 1:824 MCALPINE ST STE 6
Practice Address - Street 2:
Practice Address - City:AVOCA
Practice Address - State:PA
Practice Address - Zip Code:18641-1104
Practice Address - Country:US
Practice Address - Phone:570-701-6044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-05
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202D00000XAllopathic & Osteopathic PhysiciansIntegrative MedicineGroup - Multi-Specialty