Provider Demographics
NPI:1801408208
Name:TREASURE COAST KETAMINE WELLNESS & IV NUTRITION CENTER
Entity Type:Organization
Organization Name:TREASURE COAST KETAMINE WELLNESS & IV NUTRITION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:JARRELL
Authorized Official - Last Name:MCCRACKEN
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:352-262-8439
Mailing Address - Street 1:777 37TH ST STE B106
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-7301
Mailing Address - Country:US
Mailing Address - Phone:772-907-5917
Mailing Address - Fax:772-907-5917
Practice Address - Street 1:777 37TH ST STE B106
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-7301
Practice Address - Country:US
Practice Address - Phone:772-907-5917
Practice Address - Fax:772-907-5917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-18
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No163WI0500XNursing Service ProvidersRegistered NurseInfusion TherapyGroup - Single Specialty