Provider Demographics
NPI:1649833062
Name:ILLUMINATE KETAMINE CENTER PLLC
Entity type:Organization
Organization Name:ILLUMINATE KETAMINE CENTER PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/ PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BEASLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:423-765-0777
Mailing Address - Street 1:1936 BROOKSIDE DR STE E
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4654
Mailing Address - Country:US
Mailing Address - Phone:423-765-0777
Mailing Address - Fax:
Practice Address - Street 1:1936 BROOKSIDE DR STE E
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4654
Practice Address - Country:US
Practice Address - Phone:423-765-0777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-22
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy