Provider Demographics
NPI:1861036063
Name:PRIDE MEDICAL SPA AND WELLNESS CENTER INC
Entity Type:Organization
Organization Name:PRIDE MEDICAL SPA AND WELLNESS CENTER INC
Other - Org Name:RADIANCE KETAMINE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:775-217-0377
Mailing Address - Street 1:5365 MAE ANNE AVE STE A10
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89523-1841
Mailing Address - Country:US
Mailing Address - Phone:775-432-1500
Mailing Address - Fax:775-432-1002
Practice Address - Street 1:5365 MAE ANNE AVE STE A10
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89523-1841
Practice Address - Country:US
Practice Address - Phone:775-432-1500
Practice Address - Fax:775-432-1002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-30
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty