Provider Demographics
NPI:1912543968
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:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA, MS, BSN
Authorized Official - Phone:775-217-0332
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:2019-11-25
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty