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Ketamine Infusions of Idaho, PLLC

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Company Details

Name: Ketamine Infusions of Idaho, PLLC
Jurisdiction: Idaho
Legal type: Limited Liability Company (D)
Status: Active-Existing
Date of registration: 19 Jun 2020 (5 years ago)
Financial Date End: 30 Jun 2026
Entity Number: 3912214
Place of Formation: IDAHO
File Number: 714209
ZIP code: 83406
County: Bonneville County
Principal Address: 1534 MIDWAY AVE. AMMON, ID 83406
Mailing Address: CHRISTINA STUBBS 164 SADONA SUMMIT DR IDAHO FALLS, ID 83404-4914

Agent

Name Role Address
Daniel Wilkerson Agent 700 S WOODRUFF AVENUE, DANIEL WILKERSON, IDAHO FALLS, ID 83403

Manager

Name Role Address Appointed On Resigned On
CHRISTINA STUBBS Manager 164 SADONA SUMMIT DR, ID, ID 83404 2023-06-06 No data
Christina Stubbs Manager 1534 MIDWAY AVE., AMMON, ID 83406 2021-02-12 2023-06-06
Christina Clinton Manager 1534 MIDWAY AVE., AMMON, ID 83406 2021-02-03 2021-02-12

National Provider Identifier

NPI Number:
1730769142
Certification Date:
2021-04-09

Authorized Person:

Name:
CHRISTINA STUBBS
Role:
OWNER
Phone:

Taxonomy:

Selected Taxonomy:
261QI0500X - Infusion Therapy Clinic/Center
Is Primary:
Yes

Contacts:

Fax:
2085345838

Filing

Filing Name Filing Number Filing date
Annual Report 0006230318 2025-05-03
Annual Report Amendment 0006105043 2025-02-11
Statement of Change of Business Mailing Address 0005745421 2024-05-22
Annual Report 0005719114 2024-05-03
Annual Report 0005268961 2023-06-06

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Date of last update: 07 Jul 2025

Sources: Idaho Secretary of State