Provider Demographics
NPI:1730769142
Name:KETAMINE INFUSIONS OF IDAHO
Entity type:Organization
Organization Name:KETAMINE INFUSIONS OF IDAHO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:STUBBS
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:208-607-8401
Mailing Address - Street 1:PO BOX 3646
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-3646
Mailing Address - Country:US
Mailing Address - Phone:208-607-8401
Mailing Address - Fax:208-534-5838
Practice Address - Street 1:1582 ELK CREEK DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8322
Practice Address - Country:US
Practice Address - Phone:208-607-8401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy